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. from the papilla of Vater. Methods: Sixty-seven self-expandable biliary stents. were used in 60 patients 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 in 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 stent occlusion rate was 17% after a mean period of 4.3 months. No major complications were noted. Average survival was 132 days for group A and 140 days for group B. In group A, 19 patients survived less than or equal to 90 days and in eight of these, cholangitis occurred at least once. Of 11 patients in group A with survival > 90 days, only two developed cholangitis. In group B, 13 patients who survived less than or equal to 90 days had no episodes of cholangitis and in 17 with survival > 90 days, cholangitis occurred in three. There is a statistically significant difference (p < 0.05) regarding 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 sphincter of Oddi should also be stented in order to reduce the postprocedural morbidity. During the last decade, metallic endoprostheses have been used successfully for palliation of malignant obstructive jaundice [1]. A wide variety of different metallic stents have proved to have almost equally sufficient patency rates, without prolonging survival [2-8]. Percutaneous application of these devices has been established due to their low complication and mortality rates, especially in cases where endoscopy fails [2, 9]. More recently developed covered metallic stents failed to improve patency, so that their widespread use is not recommended [10, 11]. The most frequent late complication is cholangitis. associated with stent occlusion and icterus [5, 6, 9]. Controversy remains about the need for stentin,or of the sphincter of Oddi located in the papilla of Vater, in case the tumor spares that region 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 helpful in preventing postprocedural morbidity associated with cholangitis without coexisting biliary obstruction.