Optimum palliation of inoperable hilar cholangiocarcinoma: Comparative assessment of the efficacy of plastic and self-expanding metal stents

Background: Endoscopic retrograde biliary drainage (ERBD) with plastic or self-expanding metal stents (SEMS) is often performed for palliative care for cholangiocarcinoma. Objective: The objective was to compare the clinical effectiveness, including stent patency, complication rate, and need for salvage percutaneous transhepatic biliary drainage, of SEMS and plastic stents. Methods: A total of 100 patients with inoperable cholangiocarcinoma were identified from an endoscopic database from 1/1/01 to 9/30/06 at a tertiary cancer hospital and their clinical history was retrospectively reviewed. All patients were followed to death, re-intervention, or for at least one year. Stent patency and patient survival were estimated by Kaplan-Meier analysis, supplemented by the log-rank test for comparisons between groups. Results: Forty-eight patients had SEMS placed and 52 patients had plastic stents placed. ERBD was successful in 46 (95.8%) in the SEMS group and 49 (94.2%) in the plastic group (P = 0.67). Median patency times were 1.86 months in the plastic group and 5.56 months in the SEMS group (P < 0.0001). A mean of 1.53 and 4.60 re-interventions were performed in the SEMS and plastic groups, respectively (P < 0.05). Complications occurred in 4/48 (8.3%) in the SEMS group and 4/52 (7.7%) in the plastic group (P = 0.79). Median survival was 9.08 and 8.22 months in the SEMS and plastic stent groups, respectively (P = 0.50). Conclusion: Metallic stent patency was superior to that of plastic stents in all Bismuth-Corlette classifications of hilar cholangiocarcinoma with similar complication rates. SEMS seem to be cost-effective and, when feasible, should be considered as an initial intervention in patients with inoperable hilar cholangiocarcinoma.