Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand.
Surg Endosc. 2010 Sep;24(9):2216-20. doi: 10.1007/s00464-010-0931-3. Epub 2010 Feb 23.
Although self-expandable metallic stent (SEMS) has a longer patency than plastic stent (PS) for malignant biliary obstruction, stent occlusion can occur and drainage has to be reestablished in a patient with expected long survival. However, the choices are still controversial among restenting with SEMS, PS, and percutaneous transhepatic biliary drainage (PTBD). This study was designed to determine the efficacy and outcome of PS, SEMS, and PTBD for patients with occluded SEMS.
A total of 154 ERCPs with SEMS insertion were performed at the Endoscopy Unit of Chulalongkorn University. The causes of obstructive jaundice were cholangiocarcinoma (n = 110), pancreatic cancer (n = 41), and metastatic carcinoma (n = 3). Thirty-two patients (20.9%) with occluded SEMS (uncovered SEMS = 22 and covered SEMS = 10) were identified. PS, SEMS, and PTBD were used to reestablish drainage in 11, 14, and 7 patients, respectively. The second stent was inserted as stent-in-stent. Patients with less advanced disease were preferably opted to have a second SEMS.
The median stent patency of second SEMS (100 days) was significantly longer than PS (60 days) and PTBD (75 days; p < 0.05). The median survival time for patients with second SEMS (230 days) was significantly longer than patients with PS (130 days) and PTBD (150 days; p < 0.05). Subgroup analysis in hilar obstructions showed no statistical difference in second stent patency and survival between PS and SEMS. Pain that required oral narcotic developed in 71% (5/7) of PTBD patients.
In general, a second SEMS insertion in occluded SEMS provides a significant longer patency time than PS and PTBD. However, the benefit of SEMS as a second intervention in hilar obstructed patients is still doubtful.
虽然自膨式金属支架（SEMS）在恶性胆道梗阻中的通畅时间长于塑料支架（PS），但在预期生存时间较长的患者中，支架可能会堵塞，需要重新建立引流。然而，在使用 SEMS、PS 和经皮经肝胆管引流（PTBD）进行再介入治疗方面，选择仍存在争议。本研究旨在确定 PS、SEMS 和 PTBD 治疗支架堵塞患者的疗效和结果。
在朱拉隆功大学内镜科进行了 154 例 SEMS 插入的 ERCP。梗阻性黄疸的病因是胆管癌（n=110）、胰腺癌（n=41）和转移性癌（n=3）。确定了 32 例（20.9%）支架堵塞患者（未覆盖 SEMS=22 例，覆盖 SEMS=10 例）。分别用 PS、SEMS 和 PTBD 重新建立引流的患者有 11、14 和 7 例，第二次支架置入采用支架内支架的方式。优先选择病情较轻的患者进行第二次 SEMS 治疗。
第二次 SEMS 的中位支架通畅时间（100 天）明显长于 PS（60 天）和 PTBD（75 天；p<0.05）。第二次 SEMS 患者的中位生存时间（230 天）明显长于 PS 患者（130 天）和 PTBD 患者（150 天；p<0.05）。在肝门部梗阻的亚组分析中，PS 和 SEMS 之间第二次支架通畅时间和生存无统计学差异。PTBD 患者中有 71%（5/7）出现需要口服麻醉剂的疼痛。
总的来说，在支架堵塞的患者中，第二次 SEMS 置入比 PS 和 PTBD 提供更长的通畅时间。然而，在肝门部梗阻患者中，SEMS 作为二次介入治疗的益处仍存在疑问。
