Biliary obstruction caused by unresectable malignancy commonly is treated by placement of a biliary self-expandable metallic stent. The endoscopic and percutaneous techniques for self-expandable metallic stent placement are well established and can be performed with a high success rate. Self-expandable metallic stent placement affords palliation of pruritus and enables treatment of advanced cancer with chemotherapeutic agents metabolized by the liver. Unfortunately, these stents tend to occlude with time. Optimal management of an occluded self-expandable metallic stent remains to be determined.

A retrospective review was undertaken to determine optimal management of the occluded self-expandable metallic stent. Patients with malignant biliary obstruction who had endoscopic management for occluded Wallstents that had been placed percutaneously and endoscopically were studied. All patients underwent ERCP with one of the following interventions: mechanical cleaning, insertion of a plastic stent within the Wallstent, or insertion of a second Wallstent. The effectiveness of the intervention and duration of stent patency thereafter was studied.

A total of 34 patients with occluded biliary Wallstents underwent the following procedures: mechanical cleaning (6 patients), placement of a second Wallstent (4), or insertion of a plastic stent (24). Mechanical cleaning was effective in only one of 6 patients. For all 4 patients who underwent placement of a second Wallstent, there was resolution of jaundice or cholangitis and no reocclusion. Plastic stent insertion was successful in 22 of 24 patients. Median duration of stent patency after intervention was 192 days (range 81-257 days) after second Wallstent placement, 90 days (11-393 days) after plastic stent insertion, and 21 days (3-263 days) after mechanical cleaning. Duration of stent patency was better when the initial malignant stricture involved the distal vs. the proximal bile duct.

Occlusion of a biliary Wallstent is best managed by endoscopic insertion of a second Wallstent or a plastic stent. Mechanical cleaning is less effective. The level of the initial biliary obstruction influences stent patency.