FULLY COVERED SELF EXPANDABLE METAL STENT IN THE MANAGEMENT OF DIFFICULT CHOLEDOCOLITIASIS

Aims:

Difficult choledocholithiasis represents up to 15% of retained biliary stones and no standard treatment is codified. On this context, the temporary use of fully covered self expandable metal stent (FCSEMS) are an emergent option. Our aim was to assess the efficacy and safety of FCSEMS in the treatment of difficult common bile duct (CBD) stones.

Methods:

From February2012 to September2017 we retrospectively analysed 54 cases of difficult extrahepatic biliary stones, treated with at least one FCSEMS. Follow-up ERCP was performed for stent removal and new attempt of CBD clearance. In case of ineffectiveness, additional therapies such as ESWL, Dilation Assisted Stone Extraction (DASE) or surgery, were given. Data regarding patient's characteristics, bile duct and stone features, type of FCSEMS, adverse events, were analyzed.

Results:

FCSEMS placement was successful in all 54 patients. One patient died for massive delayed bleeding occurred after endoscopic sphincterotomy. Duct clearance with FCSEMS alone was achieved in 32 of 53 patients (60%) after a mean time of 34 days (Group A). Twenty one patients (Group B) underwent to additional treatments such as DASE (6 patients), ESWL (8 patients), ESWL+DASE (6 patients); surgery (1 patient). Univariate analysis showed the diameter of the stone was a predictive factor of unsuccessful treatment with FCSEMS alone (stone diameter 16.8 ± 5.1 mm vs. 20.3 ± 4.1 mm; p-value 0.01 and stone diameter ≥20 mm 34% vs. 67%, p-value 0.02, OR 3.8 (1.2122) in group A and B, respectively). Stent migration occurred in 11 cases. Mild adverse events occurred in 12/53 patients over 156 ERCP performed and no significant differences among the two groups were seen.

Conclusions:

FCSEMS represents a safe and effective treatment in the management of difficult choledocolitiasis. According to our case series, FCSEMS could be useful as single treatment for not giant biliary stones. Although this is the largest series available at the moment, further studies are needed to asses type of stent and its indwell time to reach best results.