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 (ERG) with biliary sphincterotomy. Interventions: Patients with incomplete stone clearance after ERG 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 ERG 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. (Gastrointest Endosc 2011;74:520-6.)