Impact of reducing duodenobiliary reflux on biliary stent patency: an in vitro evaluation and a prospective randomized clinical trial that used a biliary stent with an antireflux valve

Abstract

Background: The mechanisms leading to occlusion of plastic biliary stents (PBS) are not known.

Objective: To evaluate the impact of reducing duodenobiliary reflux on stent patency rate.

Design: A newly designed antireflux PBS (AR-PBS) was tested in vitro by using ox bile. A prospective randomized trial in human beings was conducted.

Setting: Tertiary medical center.

Patients: Patients with malignant bile-duct strictures were studied.

Interventions: A PBS or an AR-PBS stent was placed by using standard techniques, and the patients were followed at regular intervals. Patients presenting with stent occlusion underwent re-stent placement with either a PBS or a metal stent.

Main outcome measurements: In vitro: resistance to retrograde flow and comparison of the basal and peak antegrade flow pressures between the 2 stents. In vivo: stent patency rates, complications, and the efficacy of the stents in improving the liver test.

Results: The AR-PBS stent could withstand a retrograde pressure gradient of >320 mm Hg compared with <1 mm Hg for the PBS. Secondary to the siphon effect of the valve, the antegrade flow resistance offered by the AR-PBS was on the negative side for all flow rates compared with PBS (P < .001). The median patency of the AR-PBS in human studies was 145 days (range, 52-252 days) compared with 101 days (range, 41-210 days) for the PBS (P = .002). Both stents were equally effective in improving the liver test, and complication rates were similar in the 2 groups.

Limitations: The occluded stents were not examined microscopically.

Conclusions: The antireflux biliary stent remains patent for a longer time and hence duodenobiliary reflux may be contributing to stent occlusion.