Endoscopic management of biliary tract cancer with the wallstent: Experience in 121 patients

The treatment of choice for malignant biliary strictures is endoscopic stenting, either plastic or metallic. Eventhough metallic stents have shown a longer patency rate and easier placement, their use is still not widely accepted. We report our experience with the Wallstent (Schneider, Minneapolis). From Jan 1994 to Oct 1996, we treated 121 pts with biliary strictures. There were 80 men, 41 women, mean age 66.8 y (range 21-90). The strictures were due to pancreatic cancer (45), gallbladder (17), cholangiocarcinoma (16), ampulla (10), colorectal (11), hepatoma (5), breast (7), lung (4), ovarian (1), gastric (2), lymphoma (2), and adrenal (1). Index stent placement was successful in 100% (4 required a second stent for initial misplacement). Previous Rx included plastic stents (82), surgery (34), and chemoXRT (91). The mean stricture length was 2.5 cms and the location was CBD/CHD in 91, and CHD/IHD in 30. Nine pts had >1 strictures and required 2 stents. During a mean follow-up of 127 days (29-377), overgrowth occured in 3, ingrowth in 10, cholangitis in 14, tissue hyperplasia in 22, migration in 1, and hemobilia in 1. All pts with luminal stent occlusion were successfully treated with plastic stents. The patient with migration of the stent underwent surgery. The patient with hemobilia was treated with Nd-YAG laser during choledochoscopy. Four pts required choledochoscopy for laser therapy to allow passage of the plastic stent. In all, choledochoscopy showed tumor ingrowth. One pt required a second stent to avoid occlusion of the stent opening by the wall of the CBD and 1 for "extension" of the stent beyond a CHB-duodenal anastomosis to bypass a duodenal stricture. In 1, the stent was placed using the rendezvous technique. Overall, jaundice resolved in 108/121 pts (90%) and the mean stent patency rate was 9.25 months (6 weeks-14 months). All pts with residual jaundice had metastatic liver disease. There was no stent-related mortality. Fourteen pts are alive, the rest have died of disease progression. In conclusion, biliary Wallstents have a longer patency rate compared to that reported for plastic stents, provide significant relief of jaundice (90%), and are associated with minimal morbidity and no mortality. Coating of the stent may prevent tumor ingrowth. A prospective evaluation and comparison to various plastic stents is underway.

Duke Scholars

Author James Abbruzzese Medicine, Medical Oncology