Long-term outcome of endoscopic metallic stenting for benign biliary stenosis associated with chronic pancreatitis

Abstract

Aim: Endoscopic metal stenting (EMS) offers good results in short to medium term follow-up for bile duct stenosis associated with chronic pancreatitis (CP); however, longer follow-up is needed to determine if EMS has the potential to become the treatment of first choice.

Methods: EMS was performed in eight patients with severe common bile duct stenosis due to CP. After the resolution of cholestasis by endoscopic naso-biliary drainage three patients were subjected to EMS while, the other five underwent EMS following plastic tube stenting. The patients were followed up for more than 5 years through periodical laboratory tests and imaging techniques.

Results: EMS was successfully performed in all the patients. Two patients died due to causes unrelated to the procedure: one with an acute myocardial infarction and the other with maxillary carcinoma at 2.8 and 5.5 years after EMS, respectively. One patient died with cholangitis because of EMS clogging 3.6 years after EMS. None of these three patients had showed symptoms of cholestasis during the follow-up period. Two patients developed choledocholithiasis and two suffered from duodenal ulcers due to dislodgement of the stent between 4.8 and 7.3 years after stenting; however, they were successfully treated endoscopically. Thus, five of eight patients are alive at present after a mean follow-up period of 7.4 years.

Conclusion: EMS is evidently one of the very promising treatment options for bile duct stenosis associated with CP, provided the patients are closely followed up; thus setting a system for their prompt management on emergency is desirable.

Figure 1

Plotting of the serum alkaline phosphatase concentration (●) and conjugated bilirubin (○) of each patient during 3 yr after EMS. The broken line indicates the upper limit of normal.

Figure 2

No bile duct stone was observed immediately after EMS in patient number 7 (A), however, stones were noted 6.1 years later (arrow), and they were successfully removed using a basket wire (B). Peroral cholangioscopy revealed the common bile duct distal to the stone (arrow) was patent and the hyperplastic change was not conspicuous (C). Arrow head indicates the pancreatic duct stent.

Figure 3

Endoscopic view showing a duodenal ulcer on the side opposite to the duodenal papilla (A) 5.9 years after the EMS in patient number 3. The stent had become dislodged and the steel wires protruded from the papilla (B). They were efficiently cut using the end-cutter (arrow) (C).

Figure 4

Plotting of the serum alkaline phosphatase concentration (●) and conjugated bilirubin (○) of each patient 3 yr after EMS. The broken line indicates the upper limit of normal.