What are the next steps for a patient with existing biliary (bile duct) stents and duodenal (small intestine) stents?

Management of Patients with Existing Biliary and Duodenal Stents

For patients with existing biliary and duodenal stents, regular monitoring for stent patency is essential, with replacement of plastic biliary stents every 3 months and consideration of self-expandable metal stents for those with longer life expectancy.

Assessment and Monitoring

When managing patients with existing biliary and duodenal stents, the following approach is recommended:

Immediate Evaluation

• Check for signs of stent occlusion:
  • Recurrent jaundice (primary indicator of biliary stent occlusion) 1
  • Nausea, vomiting, or inability to tolerate oral intake (signs of duodenal stent occlusion)
  • Cholangitis symptoms (fever, right upper quadrant pain, jaundice)
  • Elevated liver function tests

Regular Follow-up

• Evaluate patients at each cycle of chemotherapy for toxicity and response 1
• Assess stent function every 8 weeks with clinical evaluation and ultrasound 1
• Monitor for presence of ascites that may indicate peritoneal disease progression 1

Stent Management Protocol

Biliary Stents

1. Plastic stents:

   • Require routine exchange every 3 months due to risk of occlusion 1
   • Indicated primarily for patients with life expectancy ≤3 months 1
   • Occlusion occurs due to bacterial biofilm and biliary sludge deposition 1

2. Self-expandable metal stents (SEMS):

   • Preferred for patients with life expectancy >3 months 1
   • Provide longer patency (approximately twice that of plastic stents) 1
   • Average patency of 6-7 months compared to 3-4 months for plastic stents 2
   • Less prone to occlusion due to larger diameter (approximately 10mm) 1

Duodenal Stents

• Metal stents are preferred for duodenal obstruction 1
• Median duration of patency is approximately 6 months 2
• Monitor for signs of food impaction or tumor ingrowth 3

Management of Stent Complications

Biliary Stent Occlusion

• Presents with recurrent jaundice and/or cholangitis 1
• Management options:
  1. Endoscopic stent exchange or placement of a new stent 1
  2. If endoscopic approach fails, consider percutaneous transhepatic biliary drainage 1
  3. For patients with covered SEMS, removal and replacement may be possible 1

Duodenal Stent Complications

• Complications include tumor ingrowth or stent migration 3
• Management:
  1. Endoscopic placement of a second stent (stent-in-stent) 3
  2. Consider surgical gastrojejunostomy if endoscopic management fails and patient has good performance status 1

Special Considerations

Combined Biliary and Duodenal Obstruction

• Success rates for combined endoscopic stenting approach 91-100% 4, 2
• Technical considerations:
  • If duodenal stent is already in place, biliary stenting can be performed through the mesh of the duodenal stent 4
  • A thin forward-viewing endoscope may be used to navigate through duodenal stents 5

Pain Management

• For patients with severe pain, opioids should be administered (morphine typically drug of choice) 1
• Consider percutaneous or EUS-guided celiac plexus blockade for patients with poor tolerance to opiates 1

Long-term Outcomes and Prognosis

• Median survival after combined stenting is approximately 81 days (range 2-447 days) 4
• In patients receiving chemotherapy, survival may extend to approximately 11 months 2
• Most patients (69-96%) require only a single stent placement for each type of obstruction 2

Pitfalls to Avoid

• Delaying stent exchange for plastic biliary stents beyond 3 months increases risk of cholangitis 1
• Failing to consider that recurrent jaundice usually indicates stent occlusion rather than disease progression 1
• Overlooking the possibility of accessing the biliary system through existing duodenal stents 4

By following these guidelines, patients with existing biliary and duodenal stents can achieve effective palliation with minimal need for repeat procedures, even in those with extended survival.