Complex biliary stones: treatment with removable self-expandable metal stents: a new approach (with videos)

Background Complex biliary stones often require temporary stent placement before a repeat attempt at extraction. To date, covered self-expandable metal stents (CSEMSs) have not been formally investigated for this indication. Objective To evaluate the efficacy and safety of CSEMSs in patients with retained complex biliary stones. Design Retrospective case series. Setting Large quaternary-care center. Patients Thirty-six patients (24 women) with complex biliary stones with incomplete stone clearance after endoscopic retrograde cholangiography (ERC) with biliary sphincterotomy. Interventions Patients with incomplete stone clearance after ERC with biliary sphincterotomy underwent temporary placement of CSEMSs, with subsequent removal before repeat stone extraction. Main Outcome Measurements Success achieving immediate biliary drainage and eventual complete duct clearance. Procedure-related complications were also assessed. Results CSEMS placement was successful in establishing immediate biliary drainage in all 36 patients. Complete duct clearance at repeat ERC was achieved in 29 of 35 patients after a mean duration of 6.4 weeks. Four of the remaining 6 patients underwent sequential CSEMS placement, with eventual duct clearance after multiple ERCPs. There were no complications related to biliary obstruction. One patient died of a nonbiliary cause. Of the total 42 CSEMSs placed, there were 4 cases (9.5%) of clinically insignificant stent migration. Limitations Single-center experience, retrospective design. Conclusions CSEMSs permit management of complex biliary stones, but require multiple sessions. The cost-effectiveness of this technique needs further investigation.