Endoscopic versus percutaneous biliary drainage in patients with resectable peri

Thank you dear Positivity – our pain as caretakers is unique and universal at the same time…

I do wonder about the timing of stent exchanges (my dad’s first plastic stent was placed June 8th, and even though it was working perfectly 3 months later, they scheduled to change it – I guess as a preventative measure to avoid clogging and infection, but perhaps we could wait a little longer next time? Since he gets weekly blood draws for his trial – if bili goes up a little, then we change it? Or is it better to change it before any sign of problem?)

Like you said, there’s no way around it – if they need a stent, they need it… our GI is an ERCP expert and the first stent placement went perfectly, but unfortunately this 2nd one was harder since they first tried for covered metal and could not fit it due to strictures… it took over 2 hours instead of the 20 min they told us the procedure would take. The next day he had pain, nausea, and fever – it really knocked him out but labs did not show high lipase or amylase so maybe it was a very mild case of pancreatitis. It got better and a week and a half later he had more energy again, but oof – it was a rough one. He even thinks next time instead of doing outpatient, he should stay in the hospital that night in case he has more pain and fever.

My big concern is what you mention about stents / repeat ERCPS causing more inflammation and scar tissue… I am so scared of what you said, that after 7-8 times she could no longer have stents. I wonder how long it’s truly possible to have repeat ERCP’s for and still be able to have stents…

I am so sorry she has to have external drains. How is she doing these days?

I have heard that MD Anderson prefers plastic stents, but I think you are right that none of these are truly permanent solutions. I wonder how long uncovered metal stents are supposed to last for without getting clogged… I wanted to find out about biliary bypass (so you don’t need a stent) but nobody would answer me about this procedure, and I figured the fact that it’s more of an involved procedure maybe means it’s not worth it? I mean, I don’t even know who would even consider doing this for us or whether it’s a good idea.

All my warmest wishes to you and your mom, and strength to keep going too

Thank you Mary!

I wanted to update that our GI had decided on a coated metal stent (which he said should last about 10 months and could be removed/replaced) – but during the ERCP, he found scar tissue/strictures that made it too hard to fit the larger covered metal stent, so after trying for 2 hours, he had to use plastic ones instead. I don’t know what caused the scar tissue/strictures (perhaps trauma from the first ERCP? But it was only one procedure…) but the GI said scar tissue doesn’t tend to go away so he thinks my dad will only ever be able to have plastic stents.

It sounds like uncovered metal was lowest on his list. (He said a problem with uncovered metal stents is that they can try to “rotoscope” clean them when they eventually get clogged, but that if there was an issue, they would have to resort to external biliary drains.)

My dad was told about the problem upon waking up from the twilight anesthesia, and he was so discouraged and depressed by this news that he will have to undergo ERCP’s every 3 months. The procedure really doesn’t feel like a piece of cake – especially this time, because he woke up the next day with some potential pancreatitis (a lot of pain and nausea, and a fever.) Nobody advised us properly on what to do besides hydrate (which was hard for him – he mostly slept that day), and thankfully the fever came down but the next day I insisted on taking my dad in for labs and IV hydration, and the IV hydration really helped.

Now thankfully he is more recovered and even did a short swim yesterday. He is so resilient, it amazes me… we go to the NIH this week for his 4th immunotherapy infusion, and next month he’ll have his 2nd scan. Wishing and hoping for good.
Lili

Thanks so much Mary ~

Exactly – you put it so well.

I tried reading everything I could find on biliary stents, plastic vs metal, uncovered vs covered metal… and even endoscopic biliary bypass, which I thought might be a way to solve the problem with a little harder recovery up front but less problems down the line…

But I could not find out how long SEMS (either the covered or uncovered metal stents) are supposed to work for, or whether there is any way to remove them if the patient becomes NED.

All I could find was similar to the example you shared, which states: “2. If expected survival is >4 months, SEMS is more cost-effective.”

Like you said, that doesn’t capture the details of a specific patient’s situation, nor does it address our real concerns. It only tells us which is more cost-effective for the medical industry!

Re: the comment from the article that says: “if there is no definitive management decision, plastic stenting is indicated.”

This is basically the reason we would consider a plastic one again – maybe hold off a few months and give the immunotherapy trial a chance to work?

It’s just so hard to know whether making decisions from a hopeful place like that is ok… on the other hand, it seems the doctors will take the opposite approach and make decisions from an assuming-the-worst place…

Since the realities of stage 4 can be so harsh (and the doctors so dismissive), I don’t really know how to effectively communicate any concerns related to optimistic outcomes.

For example:

My dad had the same tumor around the bile ducts upon diagnosis March 2017. For over a year, he did not require a stent. However, when there was a little growth in May 2018, he started getting elevated bilirubin and itching – so he needed a stent for the first time.

Once the stent was placed, it worked perfectly and the symptoms cleared up. Then he began the immunotherapy trial. The first scan shows stable disease.

If he were to see any shrinkage in the coming months, even if the tumor around the bile ducts just shrank a little, to where it used to be, then he could conceivably go back to not needing a stent?

About asking the doctors – my dad has an appointment this week with the local GI who performed the last ERCP (he seems kind but is not a biliary oncologist – he just knows how to place stents very well.) I will prepare questions for him. I will reach out to an interventional radiologist for their input as well.

When I called the research nurse for the TIL trial, she said any stent would make him ineligible because of infection risk – and it takes a couple months to prepare the TILs from the tumor sample. So things would have to be ok for a while without a stent for this trial to be an option – perhaps a stretch, although perhaps possible. Then again, it would be so hard to close the doors on this trial by taking a permanent stent.

Hopefully our current trial works and whatever stent choice is made is for the best…

Thank you both ~  I am not sure what to do about plastic vs metal stent in our situation, and I can’t seem to find much on biliary bypass.

My dad was diagnosed March 2017 but did not need a biliary stent until June 2018. They placed a plastic one and it worked perfectly. He then began an immunotherapy plus ablation trial on June 25 at the NIH.

On Sep 4, he’s scheduled for another ERCP to replace the plastic stent.

I’m afraid if they use a metal stent, we are asking for problems down the road (if we are lucky to make it down the road – but we are still hopeful about this trial we just started. He is feeling better the further away from chemo he gets (last Folfiri was May 8th) and recovered well from the trial radiofrequency ablation. He is tolerating the immunotherapy drugs well, got a short fever and rash which could be a good sign of efficacy, and his first scan Aug 21 was stable.)

I have heard that metal stents aren’t really designed to be in the body for more than a year or so – but they are not removable. So what happens if you survive past that? I have read of others having mangled metal stents (not sure if theirs were in the same location – ours would be the bile ducts.)

I don’t know how long the metal stent might last before being occluded, but apparently once that happens, you need ERCPs again every 3 months to place plastic stents inside the metal? So does it just delay the inevitable regular ERCPs? For how long?

If we get a plastic stent, then we are guaranteed to make him go through another ERCP in 3 months. I’m concerned that’s a lot to go through, especially when we don’t know what he’ll feel like in 3 months.

I don’t know if we can trust our doctors on this – I feel like if they say to get metal, are they just assuming my dad won’t survive long enough for the metal stent to become a problem? But what if immunotherapy works for him – then are we just guaranteeing future unsolvable problems with the metal stent?

Also stents make you ineligible for the Rosenberg TIL trial… I was holding hope that we could do that trial if his tumor near the ducts shrank enough for him not to need a stent again (like the past year.)

I read that MD Anderson prefers plastic stents – especially because metal stents become a permanent risk for infection… but our trial doctor just shrugged and said to ask the GI, but he doesn’t think metal stents cause a lot of problems and they work better. (But isn’t he just thinking short-term, and what’s best for his trial?) Our GI said to ask the oncologist. Our local oncologist said to ask the trial doctor or GI. Our MSK oncologist does not care at all (ever since my dad couldn’t do more chemo, they were totally uninterested in helping us.)

I don’t even know who to ask about the options – and what about biliary bypass? If that could be done endoscopically, perhaps it’s more invasive than an ERCP to place a stent but worth the harder upfront recovery to avoid these recurring stent issues?

Thank you and my best wishes to all here.

Gavin,

Thank you for posting this important research.  This topic has inspired many studies – it is good to see there was a randomized trial done to shed more light on this choice.

We periodically see questions about stents on the board.  My own view is management of biliary drainage is highly complex, and there are no easy laymen answers to questions such as whether plastic or metal stents are better.  Answers must consider a lot of patient details such as the location of the blockage, the patient’s general condition, what other treatment is planned, among others – and are best addressed by medical experts.  That said, we all benefit from good background information on this topic.  For those who have faced stent decisions, please post your stories – they are so helpful for others.

The article Gavin provided compares the use of stents (introduced endoscopically – through the mouth and esophagus into the bile duct blockage to open it up and keep it open) to use of catheters passed through the skin into the liver/blocked bile duct (which may drain into a collection bag and/or the small intestine) to bring down high bilirubin levels prior to resection surgery.  This decision is taken after first examining another consideration, namely, is ANY pre-operative drainage necessary?  Or should the patient simply be rushed into surgery?  I will add an example of a medical citation at the bottom that discusses this choice.

So, repeating myself here, there are two questions to think about in sequence.  The first question the doctor will consider for a resectable patient presenting with bile duct blockage, jaundice and/or high bilirubin is whether surgery should be immediately scheduled or whether drainage is needed before resection to ensure the surgery can be done more safely with fewer complications.  The second question if drainage is indicated is what form of drainage.  There are no easy answers to any of this, so be sure you have experienced doctors involved, ask a lot of questions, and if you have doubts, consider seeking a second opinion.

Regards, Mary

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2504392/