Timing of Biliary Stent Removal After Cholecystectomy in Patients with Prior Biliary Stent Placement
Biliary stents should be removed 1-2 weeks after cholecystectomy in patients who had stent placement prior to surgery. 1
Rationale for Short-Term Stenting
- Short stenting duration (1-2 weeks) is preferred because stents tend to clog rapidly and similar efficacy results have been reported with short (1-2 weeks) vs. standard (8-12 weeks) stenting duration 1
- A retrospective study of short-term stenting (mean duration 11 days) in patients with dominant biliary strictures showed symptomatic improvement in 83% of patients and significant improvement of cholestasis test results 1
- At 1 and 3 years after short-term stenting, actuarial analysis showed that 80% and 60% of patients, respectively, would not require re-intervention 1
Risks of Prolonged Stenting
- With longer stenting periods (3 months), unscheduled stent exchange often needs to be performed due to suspected stent clogging, presenting as cholangitis or jaundice 1
- Long-term deployment of metal stents could cause adverse events, including food impaction, which may impair bile flow and induce recurrence of cholecystitis 1
- Stent-related morbidity can be as high as 22.9% with prolonged stenting 2
Special Considerations
- For patients with biliary strictures, a pathological cholangiogram at the time of stent removal is a strong predictor of recurrence and may lead to consideration of surgery 2
- If endoscopic retrograde cholangiopancreatography (ERCP) is unsuccessful or not feasible, percutaneous transhepatic biliary drainage (PTBD) becomes an alternative 1
- For patients with major bile duct injuries (e.g., complete loss of common and/or hepatic bile duct continuity), carefully planned surgical treatment is required rather than just stent removal 1
Stent Type and Size Considerations
- For extrahepatic ducts, a single 10-Fr stent is typically recommended, while for hilar strictures extending into the left or right hepatic duct, two 7-Fr stents are often used 1
- Studies have shown that polyethylene stents provide better short-term (1-month) patency than Teflon models, and 10-Fr models provide longer biliary patency compared with thinner ones 1
- For biliary leaks, a small-diameter biliary stent alone is as effective and safe as endoscopic sphincterotomy followed by insertion of a large-diameter stent 3
Follow-up After Stent Removal
- After stent removal, recurrent strictures develop in approximately 20% of patients, typically within 2 years of stent removal 4
- In cases of recurrent stricture, repeated endoscopic treatment can be successful in about 13% of patients, while approximately 9% may require hepaticojejunostomy 5
- Regular monitoring of liver function tests is recommended after stent removal to detect any recurrence early 1
Practical Approach to Stent Removal
- Schedule stent removal 1-2 weeks after cholecystectomy 1
- Perform stent removal during an esophagogastroduodenoscopy 1
- Consider cholangiography at the time of stent removal to ensure resolution of the initial problem 2
- If cholangiogram shows persistent abnormality, consider extended treatment or alternative approaches 2
Remember that ERCP in patients with biliary issues should be undertaken by experienced pancreaticobiliary endoscopists to minimize complications 1.