Nitinol stents for palliative treatment of malignant obstructive jaundice:Should we stent the sphincter of Oddi in every case?

Purpose: To evaluate the necessity of metallic stenting of the sphincter of Oddi in malignant obstructive jaundice when the tumor is more than 2 cm. f rom the papilla of Vater. Methods: Sixty-seven self-expandable biliary stents. were used in 60 patien ts with extrahepatic lesions of the common hepatic or common bile duct and with the distal margin of the tumor located more than 2 cm from the papilla of Vater. Stents were placed above the papilla in 30 cases (group A) and i n another 30 with their distal part protruding into the duodenum (group B). Results: The 30-day mortality was 15%, due to the underlying disease. The s tent occlusion rate was 17% after a mean period of 4.3 months. No major com plications were noted. Average survival was 132 days for group A and 140 da ys for group B. In group A, 19 patients survived less than or equal to 90 d ays and in eight of these, cholangitis occurred at least once. Of 11 patien ts in group A with survival > 90 days, only two developed cholangitis. In g roup B, 13 patients who survived less than or equal to 90 days had no episo des of cholangitis and in 17 with survival > 90 days, cholangitis occurred in three. There is a statistically significant difference (p < 0.05) regard ing the incidence of cholangitis in favor of group A. Conclusions: In patients with extrahepatic lesions more than 2 cm from the papilla and with a relative poor prognosis (less than or equal to 3 months) , due to more advanced disease or to a worse general condition, the sphinct er of Oddi should also be stented in order to reduce the postprocedural mor bidity. During the last decade, metallic endoprostheses have been used succ essfully for palliation of malignant obstructive jaundice [1]. A wide varie ty of different metallic stents have proved to have almost equally sufficie nt patency rates, without prolonging survival [2-8]. Percutaneous applicati on of these devices has been established due to their low complication and mortality rates, especially in cases where endoscopy fails [2, 9]. More rec ently developed covered metallic stents failed to improve patency, so that their widespread use is not recommended [10, 11]. The most frequent late co mplication is cholangitis. associated with stent occlusion and icterus [5, 6, 9]. Controversy remains about the need for stentin,or of the sphincter o f Oddi located in the papilla of Vater, in case the tumor spares that regio n and does not obstruct the lower 2 cm. of the common bile duct (CBD). The purpose of this study was to explore whether this technique really is helpf ul in preventing postprocedural morbidity associated with cholangitis witho ut coexisting biliary obstruction.