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INTRODUCTION: Our center has reported endoscopic placement of multicaged, Gianturco-Rosch, expandable metal Z-stents (Gastrointest Endosc 1996:43:466(A)), with good patency and a low incidence of tumor ingrowth. The stent was hampered by excessive stiffness but has now been modified into a spiral pattern for more flexibility. We report in our endoscopic placement experience. Patients and Methods: 26 consecutive patients with malignant biliary obstruction received the new spiral Z-stent (Wilson-Cook Medical, Inc.,Winston-Salem, NC), including 15 with pancreatic CA, 6 with cholangioCA, and 5 with metastatic CA. Strictures were located in the distal common bile duct (N= 21), hepatic duct (N=2), and at or above the bifurcation (N=3). Difficult anatomy included: duodenal obstruction (N=3); occluded Wallstents (N=3); one Roux-en-Y, and one Billroth II. Four patients received Z-stents who were planned surgical candidates but required 4-6 weeks of pre-op medical treatment. Stents were placed using duodenoscopes (treatment in 19, diagnostic in 6) and a pediatric colonoscope in 1 (Olympus America, Melville, NY). Stents were placed using an 8.5-Fr preloaded introducer over a guidewire following sphincterotomy. Results: Placement was possible in 25 of 26 patients. The Roux-en-Y case was unsuccessful using the colonoscope. One case received bilateral intrahepatic stents. A long stricture received overlapping stents. There were no immediate complications. Good drainage was achieved in all patients at 30 days. Follow-Up: Of successfully stented patients, 4 of 25 underwent successful Whipple's resection with no complication. Stents were present in the resected specimens and showed no significant tumor ingrowth or incorporation into the bile duct wall. Stent migration was not seen in any of the 25. Patency: 12 patients died at a mean of 3.2 months without biliary obstruction or cholangitis. Four of 25 patients experienced recurrence of jaundice or cholangitis at a mean of 7.25 months which were documented at repeat ERCP to be secondary to tumor ingrowth in 2 and tumor overgrowth in 2. Six stents are in place and functioning at a mean of 7.5 months. Excluding operated patients, overall mean stent patency is greater than 160 days. Conclusion: The new spiral Z-stent is much more flexible and can be placed despite difficult anatomy using a new 8.5 Fr introducer. Stent patency appears to be good. A multicenter randomized comparative trial is underway to establish long-term patency rates. |
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