In our hospital, we use plastic stents for malignant biliary obstruction, usually it needs to be replaced due to its obstruction.
Due to the nature of the disease, the short life span of the patient, the possible obstruction and the need for replacement and the much more expensive metallic stent... I ask if malignant biliary stricture is worth this very expensive self expanding metallic stent?
I would tend to agree with Georgios, from a strict viewpoint of stent obstruction only. It is certainly possible that the placement of multiple simultaneous plastic stents can be sufficient if this is a short life expectancy and for palliation only. Having said that, if there is any possibility of any salvage therapy that could prolong the life of the patient, then the SEMS are always a better choice. One important consideration is that we should not only look at the cost of the stents alone. One additional ER visit for cholangitis or hospitalization or return for replacement due to obstructed plastic stents, even within the 3 months, will cost far more than having placed the SEM in the first place. That is why we are tending to just opt for the SEM immediately.
I fully agree with Mark. The quality of life, control of existing cholangitis and patency are superior with SEMS. We therefore try not to miss the opportunity for inserting SEMS in the first go whenever possible. Plastic stents often get blocked even before cholangitis is fully controlled, and the prolonged morbidity in our experience has always been costlier to patients, and sometimes terminal. Having said that, plastic stents are used in a large group of patients where we would wish to put SEMS.
Effective biliary drainage is a key factor which affects survival in this disease, From that point of wiev, we should use the most proficient way to ensure the obstruction free bile output....
I strongly agree with all the previous answers .The use of one or another treatment strategy depends on the life expectancy of the patient , the extent of the disease and the clinical condition of the patient and the possibility of a salvage therapy
First of all the life expectancy of the patients is a critical factor, and biliary drainage is the leading goal to improve both the quality and the lenght of the life expectancy of the patient. In expert hands fully covered metallic stents are safe and effective. Side effects are rare and cost effectiveness is beneficial in comparison to multiple replaced plastic stents or surgery .
In my hospital we have the same problem that you Abdallah. I agree with all colleagues, if the life expectancy if >6mo the indication is a biliary drainage (catheter then self expanding stent). What we do is: 6mo biliary drainage with catheter (don't have possibility to get a stent)
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