The Treatment of Patients with Symptomatic Common Bile Duct Stenosis Secondary to Chronic Pancreatitis Using Partially Covered Metal Stents: A Pilot Study

Background and Study Aims: Although surgery remains the gold standard for the treatment of symptomatic common bile duct stenosis associated with chronic pancreatitis, plastic and self-expandable open-mesh stents have been proposed as alternative treatments. These may dysfunction, however, mainly due to stent occlusion by clogging or by hyperplasia of inflammatory tissue. The aim of this study was to evaluate the safety and long-term results of using partially covered metal stents in this setting.
Patients and Methods: A total of 14 patients (12 men, 2 women; mean age 50 ± 3 years) underwent partially covered metal stent insertion for common bile duct stenosis secondary to chronic pancreatitis (12 alcohol-related, two idiopathic). They had all been treated previously with plastic prostheses.
Results: Either a 40-mm (n = 13) or a 60-mm (n = 1) partially covered metal stent was placed, depending on the length of the common bile duct stenosis and the level of the cystic duct bifurcation. Stent placement was successful, with resolution of cholangitis and improvement in cholestasis, in all patients. During the median follow-up period of 22 months (range 12 - 33 months) seven patients developed dysfunction of the stent and required re-treatment. At 12, 24, and 30 months, the stent patency rates were 100 %, 40 %, and 37.5 % respectively.
Conclusions: While partially covered metal stenting is safe and effective for the initial treatment of chronic pancreatitis-associated common bile duct stenosis and shows promising short-term results, long-term data show that dysfunction occurs in 50 % of cases. In light of the continued interest in nonsurgical treatment of this condition, further research is warranted to investigate new stent designs with improved long-term patency.

References

• 1 Afroudakis A, Kaplowitz N. Liver histopathology in chronic common bile duct stenosis due to chronic alcoholic pancreatitis.  Hepatology. 1981;  1 65-72
• 2 Scott J, Summerfield J A, Elias E. et al . Chronic pancreatitis: a cause of cholestasis.  Gut. 1977;  18 196-201
• 3 Littenberg G, Afroudakis A, Kaplowitz N. Common bile duct stenosis from chronic pancreatitis: a clinical and pathologic spectrum.  Medicine. 1979;  58 385-412
• 4 Sarles H, Sahel J. Cholestasis and lesions of the biliary tract in chronic pancreatitis.  Gut. 1978;  19 851-857
• 5 Devière J, Devaere S, Baize M, Cremer M. Endoscopic biliary drainage in chronic pancreatitis.  Gastrointest Endosc. 1990;  36 96-100
• 6 Stahl T J, Allen M O, Ansel H J, Vennes J A. Partial biliary obstruction caused by chronic pancreatitis.  Ann Surg. 1988;  207 26-32
• 7 Hammel P, Couvelard A, O’Toole D. et al . Regression of liver fibrosis after biliary drainage in patients with chronic pancreatitis and stenosis of the common bile duct.  N Engl J Med. 2001;  344 418-423
• 8 Aranha G V, Prinz R A, Freeark R J, Greenlee H B. The spectrum of biliary tract obstruction from chronic pancreatitis.  Arch Surg. 1984;  119 595-600
• 9 Stabile B E, Calabria R, Wilson S E, Passaro E. Stricture of the common bile duct from chronic pancreatitis.  Surg Gynecol Obstet. 1987;  165 121-126
• 10 Catalano M F, Linder J D, George S. et al . 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
• 11 Costamagna G, Pandolfi M, Mutignani M. et al . Long-term results of endoscopic management of postoperative bile duct strictures with increasing numbers of stents.  Gastrointest Endosc. 2001;  54 162-168
• 12 Pozsar J, Sahin P, Laszlo F. et al . Medium-term results of endoscopic treatment of common bile duct strictures in chronic calcifying pancreatitis with increasing numbers of stents.  J Clin Gastroenterol. 2004;  38 118-123
• 13 Davids P H, Groen A K, Rauws E AJ. et al . Randomised trial of self-expanding metal stents versus polyethylene stents for distal malignant biliary obstruction.  Lancet. 1992;  340 1488-1492
• 14 Knyrim K, Wagner H J, Pausch J, Vakil N. A prospective, randomised, controlled trial of metal stents for malignant obstruction of the common bile duct.  Endoscopy. 1993;  25 207-212
• 15 Devière J, Cremer M, Baize M. et al . Management of common bile duct stricture caused by chronic pancreatitis with metal mesh self-expandable stents.  Gut. 1994;  35 122-126
• 16 Dumonceau J M, Nicase N, Devière J. The ultraflex Diamond stent for benign bliary obstruction.  Gastroint Endosc Clin N Am. 1999;  9 541-545
• 17 O’Brien S M, Hatfield A RW, Craig P I, Williams S P. A 5-year follow-up of self-expanding metal stents in the endoscopic management of patients with benign bile duct strictures.  Eur J Gastroenterol Hepatol. 1998;  10 141-145
• 18 Van Berkel A M, Cahen D L, Van Westerloo D J. et al . Self-expanding metal stents in benign biliary strictures due to chronic pancreatitis.  Endoscopy. 2004;  36 381-384
• 19 François E, Devière J. Endoscopic retrograde cholangiopancreatography.  Endoscopy. 2002;  34 882-887
• 20 Isayama H, Komatsu Y, Tsujino T. et al . Polyurethane-covered metal stent for management of distal malignant biliary obstruction.  Gastrointest Endosc. 2002;  55 366-370
• 21 Shim C S, Lee Y H, Cho Y D. et al . Preliminary results of a new covered biliary metal stent for malignant biliary obstruction.  Endoscopy. 1998;  30 345-350
• 22 Isayama H, Komatsu Y, Tsujino T. et al . A prospective randomised study of ”covered” versus ”uncovered” diamond stents for the management of distal malignant biliary obstruction.  Gut. 2004;  53 729-734
• 23 Born P, Neuhaus H, Rosch T. et al . Initial experience with a new, partially covered Wallstent for malignant biliary obstruction.  Endoscopy. 1996;  28 699-720
• 24 Cremer M, Devière J, Sugai B, Baize M. Expandable biliary metal stents for malignancies: endoscopic insertion and diathermic cleaning for tumor ingrowth.  Gastrointest Endosc. 1990;  36 451-457
• 25 Barthet M, Bernard J P, Duval J L. et al . Biliary stenting in benign biliary stenosis complicating chronic calcifying pancreatitis.  Endoscopy. 1994;  26 569-572
• 26 Farnbacher M J, Rabenstein T, Ell C. et al . Is endoscopic drainage of common bile duct stenoses in chronic pancreatitis up-to-date?.  Am J Gastroenterol. 2000;  95 1466-1471
• 27 Kahl S, Zimmermann S, Glasbrenner B. et al . Treatment of benign biliary strictures in chronic pancreatitis by self-expandable metal stents.  Dig Dis. 2002;  20 199-203
• 28 Smits M E, Rauws E AJ, Van Gulik T M. et al . Long-term results of endoscopic stenting and surgical drainage for biliary stricture due to chronic pancreatitis.  Br J Surg. 1996;  83 764-768
• 29 Wamsteker E J, Elta J H. Migration of covered biliary self-expanding metallic stents in two patients with malignant biliary obstruction.  Gastrointest Endosc. 2003;  58 792-793
• 30 Ee H, Laurence B H. Hemorrhage due to erosion of a metal biliary stent through the duodenal wall.  Endoscopy. 1992;  24 431-432
• 31 Matsushita M, Takakuwa H, Nishio A. et al . Open-biopsy-forceps technique for endoscopic removal of distally migrated and impacted biliary metallic stents.  Gastrointest Endosc. 2003;  58 924-927