Percutaneous intervention strategies for the management of dysfunctioning biliary plastic endoprostheses in patients with malignant biliary obstruction.

503 E ndoscopic retrograde cholangiopancreatography is accepted as the first-line diagnosis and treatment modality in patients with jaundice secondary to malignant biliary obstruction. Palliation of these patients is achieved by insertion of plastic stents during the same session (1). Failure of the plastic biliary stents may be due to migration, occlusion, or malposition. A dysfunctioning plastic stent left in the biliary tract may act as a nidus and cause recurrent and persistent cholangitis. They may also lead to additional vascular complications such as pseudoaneurysm formation or bleeding. Additionally, they may perforate the hepatic capsule, causing biloma or abscess, or rarely, they may cause bowel obstruction and/or perforation with delayed migration (2). Failure of endoscopic intervention can be managed by replacing the occluded or malfunctioning endoprosthesis or inserting an additional plastic biliary stent during an endoscopic reintervention session. Endoscopy has a high success rate in removing the dysfunctioning stent with a complication rate of 0%–2% (3). If endoscopic reintervention fails or cannot be performed, the patient is then usually referred for percutaneous transhepatic intervention before open surgical extraction (4). Percutaneous intervention generally includes biliary drainage followed by insertion of a metallic self-expandable stent. A relative limiting point of this intervention is the presence of a dysfunctioning plastic stent in the biliary tree. Percutaneous removal of the dysfunctioning plastic stent or dislodgement into the bowel are the main options to manage this problem (5, 6). The present study describes our clinical experience and several different interventional techniques in the management of dysfunctioning plastic biliary endoprostheses in patients with malignant obstructive biliary disease.