Retained Biliary Plastic Stents: Clinical Presentation, Complications, and Management

Abstract

Abstract Background Biliary plastic stent (PS) mandates timely removal or replacement. The coronavirus disease 2019 (COVID-19) pandemic had affected the accessibility to medical therapy resulting in delay. We evaluated the burden of retained biliary PS, clinical profile, and impact of COVID-19 pandemic on stent retention. Material and Method Endoscopy database records between November 2019 and April 2022 were reviewed retrospectively to identify patients who had undergone stent exchange or removal > 3 months, that is, retained stents. Demography, comorbidity, indication and outcomes of index endoscopic retrograde cholangiopancreatography, size and duration of indwelling biliary PS, clinical presentation, imaging findings, cholangiography findings, stent-related complications, and stone formation and endotherapy details were noted. Results A total of 252 patients (100 [39.68%] males; median age 47 years [interquartile range [IQR] 32–56 years]) had common bile duct (CBD) stent retention. Median duration of retained CBD stent was 5 months (IQR = 4–6 months). Seventy (27.8%) were symptomatic with cholangitis (22, 8.7%), only jaundice (16, 6.3%), and only biliary abdominal pain (32, 12.7%). Sixty-one of 70 (87.1%) had abnormal imaging; 59/70 (84.3%) had new onset biliary stone or sludge (p ≤ 0.005). Stent retention > 6 months was significantly associated with stent fragmentation (0 vs. 20, p < 0.005) and choledocholithiasis (9 vs. 58, p < 0.005). Small caliber stent retention was more symptomatic (7 vs. 10 French [12/28 [42.85%] vs. 58/224 [25%], p = 0.049]). Univariate logistic regression analysis showed serum aspartate aminotransferase (AST), alkaline phosphatase levels, and CBD stent retention > 6 months were significantly associated with complications. On multivariate logistic regression analysis, serum AST > 2× upper limit normal (odds ratio [OR] = 5.487, 95% confidence interval [CI] = 3.1–9.9, p ≤ 0.005) and CBD stent retention > 6 months (OR = 8.6, CI = 3.1–23.92, p ≤ 0.005) were associated with complications. Out of 101 COVID-19 pandemic-attributed delay, 56/101 (55.44%) had symptomatic stent dysfunction. Endoscopic technical success rate was 97%, unsuccessful ones were due to large stones and impacted stents; with no mortality. Conclusion CBD PS stent retention, although mostly asymptomatic, can result in significant morbidity like jaundice, cholangitis, stent migration, fragmentation, or impaction in one-fourth of patients. Use of 7 Fr stent, retention duration > 6 months, abnormal imaging findings, and AST > twice the upper limit were significantly associated with complications. Endoscopic management was successful in 97% of patients.