What is the role of fully covered self-expandable metal stents (FCSEMS) in the treatment of benign pyloric stricture?

FCSEMS in Benign Pyloric Stricture

Balloon dilation should be the initial treatment for benign pyloric stricture, not FCSEMS placement, as stenting is reserved for refractory cases after dilation has failed. 1

Initial Management Approach

Start with balloon dilation as first-line therapy rather than proceeding directly to stent placement, as this approach is recommended by the American Gastroenterological Association for benign strictures and carries lower complication rates. 1

• Balloon dilation alone is preferred over stenting whenever feasible, with lower initial treatment failure rates (5% vs 8%) compared to dilation with stent placement. 2
• Reserve stenting only for strictures that fail to respond to repeated balloon dilation attempts. 1

When Stenting Becomes Necessary

If balloon dilation fails and stenting is required, multiple plastic stents are strongly preferred over FCSEMS for benign pyloric strictures. 1

Why Plastic Stents Are Superior to FCSEMS

• Plastic stents achieve higher relief rates (94% vs 60%) with lower complication rates (20% vs 36%) compared to FCSEMS in benign disease. 1
• FCSEMS induce tissue hyperplasia with subsequent tissue ingrowth and occlusion, making them inherently problematic for benign conditions. 2, 1
• The silicone coating on FCSEMS increases stent migration risk compared to plastic stents. 2

Specific Complications of FCSEMS in Pyloric Region

FCSEMS placement near the pylorus carries unique risks that must be anticipated:

• Increased rates of cholecystitis and pancreatitis occur with covered metallic stents compared to plastic stents. 2, 1
• Cholecystitis can result from cystic duct blockage when FCSEMS are positioned near the pylorus. 1
• These complications are not merely theoretical—they represent documented adverse events that significantly impact patient outcomes. 2

Technical Considerations If FCSEMS Is Used

If FCSEMS placement proceeds despite the preference for plastic stents:

• Stent dwell time should be 4-8 weeks before removal is considered. 2, 1
• Remove the stent only after cholangiography confirms stricture resolution—do not remove based solely on clinical improvement, as premature removal increases recurrence risk. 1
• Stricture recurrence rates can reach 30% within 2 years, necessitating long-term surveillance with liver function tests every 3-6 months. 1

Surgical Alternative

For patients with good functional status, life expectancy >2 months, and surgical fitness, laparoscopic gastrojejunostomy provides superior long-term relief compared to enteral stenting with lower rates of recurrent obstruction and re-intervention. 1

• This surgical option should be discussed with appropriate candidates before committing to repeated endoscopic interventions. 1
• Surgery becomes particularly relevant when endoscopic approaches have failed or when multiple stent exchanges are anticipated. 1

Critical Pitfalls to Avoid

• Do not use FCSEMS as first-line therapy—this violates guideline recommendations and exposes patients to unnecessary complications. 1
• Do not place FCSEMS without discussing surgical alternatives with appropriate surgical candidates, as surgery may offer better long-term outcomes. 1
• Do not remove stents without cholangiographic confirmation of stricture resolution, regardless of clinical improvement. 1
• Monitor closely for cholecystitis and pancreatitis during the stenting period, as these complications occur more frequently with FCSEMS than plastic stents. 2, 1