Stenting the GI tract When, How and which device? Biliary tract

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Stenting the GI tractWhen, How and which
device?Biliary tract

• P. H. DeprezGastroenterology
• Cliniques universitaires Saint-Luc, Université
  catholique de Louvain, Brussels, Belgium

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Indications of biliary drainage

• Malignant biliary obstruction
• Benign biliary strictures
• Postoperative injuries
• Liver transplantation
• Primary sclerosing cholangitis
• Chronic pancreatitis
• Biliary leaks
• After laparoscopic cholecystectomy
• Malignant
• Parasitic
• Rare indications
• Unextractable large CBD stones
• Gallbladder drainage

Adler DG, Baron TH, Davila RE, et al.
Gastrointest Endosc 2005621-8.
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Case 1

• C.P. 67y presenting with jaundice
• Biochemistry elevated bilirubin, ALAT, Alc
  Phosphatases
• US dilated bile ducts, mass head of pancreas
• MRI obstructive pancreatic mass, multiples liver
  metastasis
• Multidisciplinary oncological discussion
  palliative drainage Gemcitabine

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Questions?

• Which stent?
• Metal or Plastic?
• Type of metal stent?
• If metal covered or non covered?
• Tricks for metal stent placement?
• What should you do in case of obstruction?
• What about duodenal obstruction?

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Case 1

• SEMS or CSEMS (palliative)

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Metal stents

• Type
• Woven mesh type (Wallstent)
• Spiral type (Endocoil, Instent)
• Z stents (Gianturco Zilver Cook)
• Material
• Elgiloy (cobaly based alloy Wallstent)
• Nitinol (super elastic nickel- titanium alloy
  with thermal shape memory, Zilver Stent))
• Platinol (WallFlex RX Biliary Stent )
• Coating
• None, partially, totally covered
• Permalume covering silastic polymer Wallstent
  and Wallflex
• Fully polyurethane-covered Niti-S stents
  (Taewoong Medical, Seoul,Korea)
• SHIM-HANAROSTENT Covered Biliary Stent
• Viabil (Gore)

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Device choice Plastic vs. Metal

• Metal stents (self-expandable metal stent SEMS or
  covered self-expandable metal stent CSEMS) are
  preferred in
• Extrahepatic malignant obstruction
• If unresectable tumour or inoperable patient
• Hilar cancer (Klatskin tumours)
• If malignancy is certain or strongly suspected
• For palliation in unresectable tumours or
  inoperable patients
• Reasons
• Longer patency
• Improved life expectancy
• Needs less balloon or mechanical dilation
• Lower rate of complications
• Cost-effectiveness compared with plastic stents

Cochrane Database Syst Rev. 2006 Apr
19(2)CD004200 Chen JL, Bruno MJ, Bergman JJ,
et al. Gastrointest Endosc. 2002563339 Soderlun
d C, Linder S. Gastrointestinal Endoscopy
200663986-995
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Distal malignant obstructionMetal or plastic?

• Cochrane 2006
• Metal stents lower risk of obstruction RR 0.052
• Davids et al Lancet 1992
• Prat et al GIE 1998
• Levy et al Clin Gastroenterol Hepatol 2004
• Soderlund et al GIE 2006
• Kassis et al GI Endoscopy, 2003 57 178-182.
• No sig. other differences
• Neither Teflon, hydrourethane or hydrophilic
  coating improves patency
• 1 trial reporting higher patency with covered
  SEMS
• Weber et al. Pancreas 2008
• SEMS sig. better patency (occlusion 33 at 57
  days vs. 19 at 126 days)
• SEMS offered better survival
• Chen et al. Clin Gastroenetrol Hepatol 2005
• In ERCP before definite pancreatic cancer staging
  short length SEMS are cost effective

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Device choice SEMS vs. CSEMS

• Uncovered metal stent for
• Hilar tumours
• To improve secondary branches drainage through
  the mesh
• Ampulloma
• To avoid stent migration in case of 4cm stent
  placement
• Covered metal stent for
• Lower CBD malignant strictures
• To improve long term patency
• What about cystic duct and gallbladder?
• There are still controversies on the use of
  covered vs. uncovered stents in case of intact
  gallbladder

Isayama H, Komatsu Y, Tsujino T, et al. Gut
200453 729-34 Kahaleh M, Tokar J, Conaway MR,
et al. Gastrointest Endosc 200561528-33. Nakai
Y, Isayama H, Komatsu Y, et al. Gastrointest
Endosc 200562742-8.
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Single plastic stent Malignant obstruction
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Covered metal stent in distal obstruction
(ampulloma)
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Procedure flowStep 1 cannulation and guidewire
insertion

• Use of a pre-loaded tapered tip sphincterotome
  with a guidewire
• When approaching the papilla the sphincterotome
  should be flexed in alignment with the perceived
  CBD orientation
• The tip is inserted in the common channel or
  ampulla, then either
• start with injection of small amounts of contrast
  (to show the distal part of the ducts and
  orientate to the bile duct and to avoid
  overfilling of the pancreatic duct)
• direct insertion of hydrophilic soft tip
  guidewire in the appropriate angle, sometimes
  simultaneously with small amounts of contrast, to
  open the duct
• Once guidewire placed in the CBD, the
  sphincterotome should be advanced a few mm in the
  CBD to give more stability for further guidewire
  movements
• Chen et al. Gastrointestinal Endosc 2007,
  65385-393

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Procedure flowStep 2 Deep guidewire insertion

• Distal CBD strictures are usually easily passed
  with hydrophilic guidewires
• In case of difficulties, the tricks are to
• Create a guidewire loop to pass the stricture
• Inject contrast medium to show the route through
  the stricture
• Manoeuvre the sphincterotome tip towards the
  stricture passage
• Exchange the guidewire to a different one
• Hilar strictures need more experience
• IHBD contrast filling should only be done after
  deep guidewire insertion in the intrahepatic bile
  ducts
• To avoid cholangitis in undrained bile ducts
• Placing 2 or 3 guidewires in the right and left
  IHBD before stenting is preferable
• The guidewires should be placed in ducts avoiding
  sharp curves
• If these steps take more time than expected I
  prefer to
• perform a sphincterotomy to decompress the
  pancreatic
• orifice and decrease risk of acute pancreatitis

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Procedure flowStep 5 Metal stent insertion

• Stent deployment
• Advance the stent across the site of the
  stricture
• use up-and-down or lateral movements with the
  scope to advance in tight stricture
• allow some time for the tapered tip of the stent
  to pass the stricture
• Position the distal marker at least 1 cm above
  the upper part of the stricture
• Be aware of stent shortening during deployment
• Use fluoroscopic and endoscopic monitor during
  placement
• Avoid single stent placement when very close to
  the hilum (placement of two stents preferable to
  maintain access to the 2 liverlobes
• Reposition the stent during deployment if
  necessary for optimal distal (1 cm margin above
  the lesion) and proximal (mesh visible outside de
  papilla) deployment
• Retrieve the delivery system
• To facilitate retrieval of the delivery system,
  the exterior tube and handle should be pushed
  back against the tip and then pulled all together
  through the endoscope
• In tight or sharp strictures excessive traction
  on the delivery system should be avoided
• Dilation of a deployed SEMS is not necessary,
  full expansion may take 24 hours

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Procedure flowStep 5 Metal stent insertion
difficult situations

• In case of multiple metal stents
• The most difficult anatomy should be stented
  first (left liver usually, where curve is
  sharper)
• The first stent should extent a few mm outside
  the papilla to avoid that its braid might damage
  or block second stent to advance
• The second or next stent should be preloaded on
  the second guidewire, ready to be pushed through
  the scope accessory channel as soon as the first
  delivery system is retrieved
• The second stent should be passed as soon as
  possible beside the first stent
• In case of associated duodenal stenosis
• Duodenum might necessitate balloon dilation for
  proper duodenoscope positioning
• Biliary should be performed first (always metal
  stent for optimal long term patency)
• Biliary stent should extent out of the papilla
  for 5-10 mm (some shortening will occur, stent
  should remain visible in case of late obstruction
• In case of metal stent obstruction
• Cleaning might be sufficient if obstruction is
  caused by sludge or lithiasis
• Repositioning a second metal stent (covered or
  longer) inside a stent occluded due to malignant
  progression is preferable to placement of plastic
  stents

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Obstruction of SEMS Extraction of stones New
stent
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Case 2

• 81 y old male patient
• Jaundice
• MRI hilar mass
• EUS FNA adenocarcinoma

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Case 2 questions

• Which stent?
• -Plastic or SEMS
• -Covered or non covered
• One or more stents?
• Length?
• Are metal stents extractable?
• Sphincterotomy?
• Dilation?

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Case 2

• multiple SEMS (palliative)

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Metal stent insertion

• Insertion over guidewire
• sometimes superstiff guidewire preferable
  (Klastkin tumour)
• In case of multiple stent placement
• The guidewires should all be in place
• The stents should be prepared so that each can be
  inserted before full expansion of the first
• Extent of drainage depends on extent of tumour
  involvement in the liver, respective atrophy of
  each lobe and ease of guidewire access
• Cochrane Database Syst Rev. 2006 Apr
  19(2)CD004200

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Device choice length of stent

• Length of lesion should be measured during ERCP
• Either on fluoroscopy (endoscope as reference for
  measuring)
• Either on the catheter or guide-wire (pre-marked
  or by measuring when pulling back)
• Allow 1cm above and below the lesion to prevent
  overgrowth
• Tips and tricks
• Distal CBD strictures
• Stent should extent 5-10 mm outside the papilla
  to facilitate recannulation in case of
  obstruction
• Stent should avoid covering the hilum to decrease
  risk of stent induced strictures
• Proximal biliary strictures including Klatstkin
  tumours
• Long stents (10-15 cm) should be used (ideally
  bilateral)
• Stent(s) should extent out of the papilla to
  facilitate further access to the ducts
• Bilateral drainage will also facilitate further
  right and left accesses in case of recurrent
  obstruction

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Extraction of Wallstent
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Sphincterotomy?

• Role of sphincterotomy before biliary stent
  placement is unproven
• Sphincterotomy is not necessary for placement of
  10F plastic stents and increases acute procedural
  morbidity (ref 1)
• Sphincterotomy should be avoided in high risk
  patients for bleeding (cirrhosis,anticoagulants)
• In distal benign and malignant strictures,
  placement of a stent without biliary
  sphincterotomy might obstruct the pancreatic
  orifice (ref 2)
• In my practice, use of sphincterotomy, before
  metal stent placement has decreased post-ERCP
  acute pancreatitis

(1) Margulies C, Siqueira ES, Silverman WB, Lin
XS, Martin JA, Rabinovitz M, Slivka A.
Gastrointest Endosc. 1999 Jun49(6)716-9. (2)
Tarnasky PR, Cunningham JT, Hawes RH, Hoffman BJ,
Uflacker R, Vujic I, Cotton PB. Gastrointest
Endosc. 1997 Jan45(1)46-51
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Dilation?

• Dilation during metal stent placement is rarely
  necessary, except in some steep curves in
  Klatskin tumours
• Dilation during plastic stents will often be
  necessary in case of
• Multiple stent placements for benign strictures
• Single large diameter stent placement in chronic
  strictures (chronic calcifying pancreatitis, late
  post-op strictures)
• Proximal CBD and hilar tight or curved strictures
• Balloon dilation preferable to mechanical
  dilation (more radial force, larger dilation
  calibration)
• diameter preferably 6-8 mm to allow multiple
  stent placement
• Balloon length of 4 cm increases stability during
  dilation of very short stricture and achieves
  easier dilation of long strictures

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Case 3

• 35y female patient
• Recurrent biliary pain
• Elevated alc phosphatases and ASAT/ALAT
• ERCP distal short biliary stricture
• EUS no mass, FNA neg

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Case 3 questions

• Which stent?
• Single or multiple?
• Special type?
• Duration of stenting?

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Case 3

• Multiple plastic stents

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Device choice Plastic vs. Metal

• Plastic stents are preferred in
• Benign post-operative strictures
• Bile leaks
• Distal CBD in chronic pancreatitis
• Pre-operative drainage in malignant strictures
• Hilar stricture of unknown cause
• Unextractable giant stones
• Reasons
• Ease of use, low cost, wide distribution
• Some tricks
• Multiples (2-4) large diameter (8.5-10 Fr) stents
  will perform better to achieve permanent dilation
  in benign diseases
• Minimum stent calibration duration one year
• Systematic stent exchange/3 months preferable
  when single stent in place

Levy MJ, Baron TH, Gostout CJ, et al. Clin
Gastroenterol Hepatol 20042273-85
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Plastic stents

• Material
• Polyethylene
• Modifications of surface coating
• Teflon coating (Tannenbaum, Cook))
• Double layer, Polymer-coated polyurethane
  (Olympus)
• Straight or curved
• With or without sideholes
• 5-12 Fr
• 1-15 cm
• Clogging is caused by dietary fibers and bioflm
  peritteing adherence of bacteria, then
  deconjugation of biles salts and precipitation of
  clacium bilirubinate and fatty acids sludge and
  stones
• Consequences
• 30 occlusion at 3 months and 70 after 6 months
• Need exchange after 3 months
• Often placed initially and further SEMS when
  inoperable and survival gt6m

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New plastic

• Biliary stents without lumen
• Raju et al GIE 2006 63317
• Jolin (Cook) multiperforated flexible
• Boursier et al GCB 2008
• Anti-reflux (Cook)
• Dua et al GIE 200765819

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Plastic in benign diseases

• Costamagna et al GIE 200154162
• Draganov et al GIE 200255680
• Catalano et al. GIE 200460945
• Success rate 80 after 6 to 18 months stenting

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Multiple plastic stents -tumour -fistula
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Plastic Stent insertion

• Single stent
• The stent should be advanced over the guidewire
  with an introducer set to facilitate passage of
  the stricture
• Multiples stents
• Dilatation is often necessary and can be
  performed before insertion of the stents or/and
  after each placement
• Use of single of multiple guidewire will depend
  on the expertise and anatomy during recannulation
• Respective length of the stents will depend on
  length and anatomy of the stricture and efficacy
  of dilation.
• In difficult stricture the first stent might be 1
  or 2 cm longer than the next stents to avoid
  proximal migration
• Number of stents will depend on bile duct size

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Multiple plastic stents -benign
strictures -fistula
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EBM for biliary stenting?

• Plastic stents
• Malignant (distal or proximal) obstruction before
  surgery
• Malignant obstruction before staging
• Malignant obstruction if life expectancy less
  than 4 m
• Benign strictures (multiple stents)
• Bile leaks
• SEMS
• Palliation of hilar cancers
• CSEMS
• Unresectable extrahepatic malignancy (with
  prolonged survival)

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Provocative indications?

• SEMS
• Distal malignant operable obstruction?
• CSEMS for
• Benign strictures (CP)

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CSEMS in CP