Clinical Endoscopy

The Korean Society of Gastrointestinal Endoscopy (대한소화기내시경학회)
권호 표지

The Efficacy and Safety of Fully Covered Self-expandable Metal Stents in Benign Extrahepatic Biliary Strictures

양성 간외 담관 협착에서 완전 피막형 자가팽창성 금속 스텐트의 유용성과 안전성

  • Kim, Byeong-Uk (Department of Internal Medicine, Chungbuk National University College of Medicine) ;
  • Goo, Ja-Chung (Department of Internal Medicine, Chungbuk National University College of Medicine) ;
  • Cho, Young-Shim (Department of Internal Medicine, Chungbuk National University College of Medicine) ;
  • Han, Jung-Ho (Department of Internal Medicine, Chungbuk National University College of Medicine) ;
  • Yoon, Soon-Man (Department of Internal Medicine, Chungbuk National University College of Medicine) ;
  • Chae, Hee-Bok (Department of Internal Medicine, Chungbuk National University College of Medicine) ;
  • Park, Seon-Mee (Department of Internal Medicine, Chungbuk National University College of Medicine) ;
  • Youn, Sei-Jin (Department of Internal Medicine, Chungbuk National University College of Medicine)
  • 김병욱 (충북대학교 의과대학 내과학교실) ;
  • 구자충 (충북대학교 의과대학 내과학교실) ;
  • 조영심 (충북대학교 의과대학 내과학교실) ;
  • 한정호 (충북대학교 의과대학 내과학교실) ;
  • 윤순만 (충북대학교 의과대학 내과학교실) ;
  • 채희복 (충북대학교 의과대학 내과학교실) ;
  • 박선미 (충북대학교 의과대학 내과학교실) ;
  • 윤세진 (충북대학교 의과대학 내과학교실)
  • Published : 2011.01.30
⟨ Previous Next ⟩

Abstract

Background/Aims: For the endoscopic treatment of benign biliary strictures (BBS), it has been a drawback to use plastic stents or uncovered self-expandable metal stents. We investigated the efficacy and safety of temporary placing fully covered self-expandable metal stents (FCSEMS) in BBS. Methods: We enrolled 12 cases that followed up more than 6 months after insertion of a FCSEMS in BBS via ERCP. The cohort consisted of 9 patients with recurrent cholangitis, 2 patients with postcholecystectomy and 1 patient with chronic pancreatitis. The efficacy was assessed according to the resolution of strictures and also the restricture after stent removal, and the safety was evaluated according to the complications associated with stent placement. Finally, the removability of FCSEMSs was assessed. Results: The median time of FCSEMS placement was 6.0 months. Resolution of the BBS was confirmed in 8 cases (67%) after a median post-removal follow-up of 8.5 months. Restricture after stent removal happened in 4 cases (33%). The complications were severe abdominal pain (n=2), pancreatic abscess (n=1) and stent migration (n=6). In 7 cases, all the FCSEMSs were successfully removed by grasping them with forceps. Conclusions: Temporary placement of a FCSEMS in BBS showed good therapeutic effects, relative safety and easy removability. Further evaluation is needed for determining the causes of restricture and for developing a new stent with antimigration features.

목적: 플라스틱 스텐트는 내경이 제한되어 있어 양성 담관 협착의 치료로 널리 이용하기에는 어려운 점이 있다. 저자들은 양성 담관 협착에서 완전 피막형 자가팽창성 금속 스텐트(fully covered self-expandable metal stent, FCSEMS)의 유용성과 안전성을 알아보고자 하였다. 대상 및 방법: 양성 담관 협착으로 FCSEMS를 삽입한 후 6개월 이상 추적한 12예(남 : 여=4 : 8, 평균나이 67세)를 대상으로 하였다. 담관 협착 12예(재발성 담관염 9예, 담낭절제술 후 손상 2예, 만성 췌장염 1예)에서 내시경 역행성 담췌관조영술로 각각 1개의 FCSEMS를 유두부를 관통하여 삽입하였다. 스텐트 유치와 관련된 합병증을 조사하여 안정성을 평가하였고, 협착 해소 여부와 스텐트 제거 후 재협착으로 스텐트의 효능을 평가하였으며, 스텐트의 제거 용이성을 조사하였다. 결과: 담관 협착이 있었던 12예는 모두 시술 당일부터 증상이 완화되었다. FCSEMS는 6.0개월(중앙값)간 유치하였으며, 스텐트 제거 후 8.5개월(중앙값)에 8명은 지속적으로 협착 증상이 해소되었고 4명은 스텐트 제거 후 재협착이 발생하였다. 스텐트 유치와 관련한 합병증은 심한 복통 2예, 췌장농양 1예, 스텐트 이탈 6예(십이지장 이탈 5예, 근위부 담관 이탈 1예)였다. 스텐트를 제거를 시도한 7예 모두 겸자로 쉽게 제거하였다. 결론: 양성 담관 협착에서 FCSEMS는 치료 효과가 신속하고 안전하며 쉽게 제거할 수 있는 장점이 있다. 그러나, 스텐트 제거 후 재협착의 빈도가 높고 이탈율이 높은 점은 향후 해결해야 할 과제로 생각한다.

Keywords

References

  1. Costamagna G, Shah SK, Tringali A. Current management of postoperative complications and benign biliary strictures. Gastrointest Endosc Clin N Am 2003;13:635-648. https://doi.org/10.1016/S1052-5157(03)00103-X
  2. Judah JR, Draganov PV. Endoscopic therapy of benign biliary strictures. World J Gastroenterol 2007;13:3531-3539.
  3. Gibbons JC, Williams SJ. Progress in the endoscopic management of benign biliary strictures. J Gastroenterol Hepatol 1998;13:116-124. https://doi.org/10.1111/j.1440-1746.1998.tb00625.x
  4. Bourke MJ, Elfant AB, Alhalel R, Scheider D, Kortan P, Haber GB. Sphincterotomy-associated biliary strictures: features and endoscopic management. Gastrointest Endosc 2000;52:494-499. https://doi.org/10.1067/mge.2000.108970
  5. Costamagna G. Covered self-expanding metal stents in benign biliary strictures: not yet a "new paradigm" but a promising alternative. Gastrointest Endosc 2008;67:455-457. https://doi.org/10.1016/j.gie.2007.10.006
  6. van Boeckel PG, Vleggaar FP, Siersema PD. Plastic or metal stents for benign extrahepatic biliary strictures: a systematic review. BMC Gastroenterol 2009;9:96. https://doi.org/10.1186/1471-230X-9-96
  7. Libby ED, Leung JW. Prevention of biliary stent clogging: a clinical review. Am J Gastroenterol 1996;91:1301-1308.
  8. Catalano MF, Linder JD, George S, Alcocer E, Geenen JE. Treatment of symptomatic distal common bile duct stenosis secondary to chronic pancreatitis: comparison of single vs. multiple simultaneous stents. Gastrointest Endosc 2004;60:945-952. https://doi.org/10.1016/S0016-5107(04)02275-8
  9. Costamagna G, Pandolfi M, Mutignani M, Spada C, Perri V. Long-term results of endoscopic management of postoperative bile duct strictures with increasing numbers of stents. Gastrointest Endosc 2001;54:162-168. https://doi.org/10.1067/mge.2001.116876
  10. Pozsar J, Sahin P, Laszlo F, Topa L. Endoscopic treatment of sphincterotomy-associated distal common bile duct strictures by using sequential insertion of multiple plastic stents. Gastrointest Endosc 2005;62:85-91. https://doi.org/10.1016/S0016-5107(05)00547-X
  11. Deviere J, Cremer M, Baize M, Love J, Sugai B, Vandermeeren A. Management of common bile duct stricture caused by chronic pancreatitis with metal mesh self expandable stents. Gut 1994;35:122-126. https://doi.org/10.1136/gut.35.1.122
  12. van Berkel AM, Cahen DL, van Westerloo DJ, Rauws EA, Huibregtse K, Bruno MJ. Self-expanding metal stents in benign biliary strictures due to chronic pancreatitis. Endoscopy 2004;36:381-384. https://doi.org/10.1055/s-2004-814319
  13. Familiari P, Bulajic M, Mutignani M, et al. Endoscopic removal of malfunctioning biliary self-expandable metallic stents. Gastrointest Endosc 2005;62:903-910. https://doi.org/10.1016/j.gie.2005.08.051
  14. Shin HP, Kim MH, Jung SW, et al. Endoscopic removal of biliary self-expandable metallic stents: a prospective study. Endoscopy 2006;38:1250-1255. https://doi.org/10.1055/s-2006-944969
  15. Cantu P, Hookey LC, Morales A, Le Moine O, Deviere J. The treatment of patients with symptomatic common bile duct stenosis secondary to chronic pancreatitis using partially covered metal stents: a pilot study. Endoscopy 2005;37:735-739. https://doi.org/10.1055/s-2005-870130
  16. Kahaleh M, Behm B, Clarke BW, et al. Temporary placement of covered self-expandable metal stents in benign biliary strictures: a new paradigm? (with video). Gastrointest Endosc 2008;67:446-454. https://doi.org/10.1016/j.gie.2007.06.057
  17. Behm B, Brock A, Clarke BW, et al. Partially covered self-expandable metallic stents for benign biliary strictures due to chronic pancreatitis. Endoscopy 2009;41:547-551. https://doi.org/10.1055/s-0029-1214708
  18. Cahen DL, Rauws EA, Gouma DJ, Fockens P, Bruno MJ. Removable fully covered self-expandable metal stents in the treatment of common bile duct strictures due to chronic pancreatitis: a case series. Endoscopy 2008;40:697-700. https://doi.org/10.1055/s-2008-1077353
  19. Mahajan A, Ho H, Sauer B, et al. Temporary placement of fully covered self-expandable metal stents in benign biliary strictures: midterm evaluation (with video). Gastrointest Endosc 2009;70:303-309. https://doi.org/10.1016/j.gie.2008.11.029
  20. Davids PH, Tanka AK, Rauws EA, et al. Benign biliary strictures. Surgery or endoscopy? Ann Surg 1993;217:237-243. https://doi.org/10.1097/00000658-199303000-00004
  21. Dumonceau JM, Deviere J, Delhaye M, Baize M, Cremer M. Plastic and metal stents for postoperative benign bile duct strictures: the best and the worst. Gastrointest Endosc 1998;47:8-17. https://doi.org/10.1016/S0016-5107(98)70292-5
  22. Bergman JJ, Burgemeister L, Bruno MJ, et al. Long-term follow-up after biliary stent placement for postoperative bile duct stenosis. Gastrointest Endosc 2001;54:154-161. https://doi.org/10.1067/mge.2001.116455
  23. Draganov P, Hoffman B, Marsh W, Cotton P, Cunningham J. Long-term outcome in patients with benign biliary strictures treated endoscopically with multiple stents. Gastrointest Endosc 2002;55:680-686. https://doi.org/10.1067/mge.2002.122955
  24. Kassab C, Prat F, Liguory C, et al. Endoscopic management of post-laparoscopic cholecystectomy biliary strictures. Long-term outcome in a multicenter study. Gastroenterol Clin Biol 2006;30:124-129. https://doi.org/10.1016/S0399-8320(06)73127-X
  25. Vitale GC, Tran TC, Davis BR, Vitale M, Vitale D, Larson G. Endoscopic management of postcholecystectomy bile duct strictures. J Am Coll Surg 2008;206:918-923. https://doi.org/10.1016/j.jamcollsurg.2008.01.064
  26. Sakai Y, Tsuyuguchi T, Ishihara T, et al. Long-term prognosis of patients with endoscopically treated postoperative bile duct stricture and bile duct stricture due to chronic pancreatitis. J Gastroenterol Hepatol 2009;24:1191-1197. https://doi.org/10.1111/j.1440-1746.2009.05878.x
  27. Silvis SE, Sievert CE Jr, Vennes JA, Abeyta BK, Brennecke LH. Comparison of covered versus uncovered wire mesh stents in the canine biliary tract. Gastrointest Endosc 1994;40:17-21. https://doi.org/10.1016/S0016-5107(94)70004-4
  28. Kahaleh M, Tokar J, Le T, Yeaton P. Removal of self-expandable metallic Wallstents. Gastrointest Endosc 2004;60:640-644. https://doi.org/10.1016/S0016-5107(04)01959-5
  29. Lee SY, Lee HS, Yoon WJ, et al. Analysis of factors influencing the long term outcome after endoscopic stenting for benign biliary stricture. Korean J Gastrointest Endosc 2006;32:21-26.
  30. Ho H, Mahajan A, Gosain S, et al. Management of complications associated with partially covered biliary metal stents. Dig Dis Sci 2010;55:516-522. https://doi.org/10.1007/s10620-009-0756-x
  31. Moon SH, Kim MH, Park do H, et al. Modified fully covered self-expandable metal stents with antimigration features for benign pancreatic-duct strictures in advanced chronic pancreatitis, with a focus on the safety profile and reducing migration. Gastrointest Endosc 2010;72:86-91. https://doi.org/10.1016/j.gie.2010.01.063
  32. Leung JW, Ling TK, Kung JL, Vallance-Owen J. The role of bacteria in the blockage of biliary stents. Gastrointest Endosc 1988;34:19-22. https://doi.org/10.1016/S0016-5107(88)71223-7