No Need to Try, Try, Try Again
Fewer ERCPs Needed to Treat Benign Biliary Strictures Thanks to Expandable Stents
by Kimberly McGhee
Placement of a single covered, self-expanding metallic stent (cSEMS) via endoscopic retrograde cholangiopancreatography (ERCP) resolved benign obstructions of the bile ducts as well as placement of multiple plastic stents, the current standard of care, and required fewer ERCP sessions, according to the results of a randomized controlled trial reported in the March 22, 2016 issue of Journal of the American Medical Association. These findings will change practice in the opinion of Gregory A. Coté, M.D., an endoscopist at the MUSC Health Digestive Disease Center, lead author of the article, and the national principal investigator for the eight-center study. B. Joseph Elmunzer, M.D., of the MUSC Health Digestive Disease Center is also a co-author.
“For appropriately selected patients who are presenting for the first time with a blockage, many endoscopists will change their strategy and use these newer stents, in an effort to reduce the total procedures that are required,” said Coté.
For now, the use of cSEMS in benign biliary strictures would be off-label, as they have been approved by the FDA only for the treatment of malignant biliary strictures, such as those which develop in the setting of unresectable pancreatic cancer.
Left untreated, benign biliary strictures can lead to jaundice, cholangitis (i.e., infection of the bile duct), and secondary biliary cirrhosis. Benign strictures most often occur after liver transplantation and gallbladder surgery or as a result of chronic pancreatitis. ERCP is preferred to surgery in these patients because it is less invasive.
ERCP is an endoscopic procedure in which a camera is introduced through the mouth and advanced first to the proximal duodenum and then, using endoscopy and fluoroscopy, into the pancreatic and bile ducts. Although highly effective, three to four ERCP sessions are typically required to fully stretch the blockage and minimize the chance of recurrence once the stents are removed. Because ERCP is not without its risks—complications include acute pancreatitis, infections, bowel perforation, and bleeding—minimizing the number of sessions needed to successfully treat the stricture benefits patients. Coté designed the trial to determine whether fewer ERCP sessions would be required to treat benign strictures with the use of the larger cSEMS.
The primary endpoint of the trial, which enrolled 112 patients, was the rate of benign stricture resolution after no more than 12 months of stenting. cSEMS were found to be noninferior to plastic stents for achieving stricture resolution and they did so more quickly (181 vs. 225 days) and with fewer ERCP sessions (2.14 vs. 3.24). It should be noted that the study had careful enrollment criteria; patients with small (less than 6 mm)bile ducts and those with intact gall bladders were excluded. “We were careful not to cross the gall bladder insertion into the bile duct in patients who still had their gall bladder because you don’t want to block the gall bladder and potentially create a new problem,” said Coté.
Although the procedure can be performed by anyone proficient in ERCP, high-volume providers who are comfortable placing and removing cSEMS will likely achieve the best results.
“We can’t universally change practice based on these findings, but, in appropriately selected patients with benign bile duct strictures, deployment of cSEMS via ERCP should be first-line treatment,” said Coté.