SNFGE SNFGE
 
Thématique :
- Foie
Originalité :
Intermédiaire
Solidité :
Intermédiaire
Doit faire évoluer notre pratique :
Immédiatement
 
 
Nom du veilleur :
Professeur Jean-Marie PERON
Coup de coeur :
 
 
Journal of the American Medical Association (JAMA)
  2016/04  
 
  2016 Mar 22-29;315(12):1250-7  
  doi: 10.1001/jama.2016.2619  
 
  Effect of Covered Metallic Stents Compared With Plastic Stents on Benign Biliary Stricture Resolution: A Randomized Clinical Trial.  
 
  Coté GA, Slivka A, Tarnasky P, Mullady DK, Elmunzer BJ, Elta G, Fogel E, Lehman G, McHenry L, Romagnuolo J, Menon S, Siddiqui UD, Watkins J, Lynch S, Denski C, Xu H, Sherman S  
  http://www.ncbi.nlm.nih.gov/pubmed/?term=Effect+of+Covered+Metallic+Stents+Compared+With+Plastic+Stents+on+Benign+Biliary+Stricture+Resolution%3A+A+Randomized+Clinical+Trial.  
 
 

IMPORTANCE:

Endoscopic placement of multiple plastic stents in parallel is the first-line treatment for most benign biliary strictures; it is possible that fully covered, self-expandable metallic stents (cSEMS) may require fewer endoscopic retrograde cholangiopancreatography procedures (ERCPs) to achieve resolution.

OBJECTIVE:

To assess whether use of cSEMS is noninferior to plastic stents with respect to stricture resolution.

DESIGN, SETTING, AND PARTICIPANTS:

Multicenter (8 endoscopic referral centers), open-label, parallel, randomized clinical trial involving patients with treatment-naive, benign biliary strictures (N = 112) due to orthotopic liver transplant (n = 73), chronic pancreatitis (n = 35), or postoperative injury (n = 4), who were enrolled between April 2011 and September 2014 (with follow-up ending October 2015). Patients with a bile duct diameter less than 6 mm and those with an intact gallbladder in whom the cystic duct would be overlapped by a cSEMS were excluded.

INTERVENTIONS:

Patients (N = 112) were randomized to receive multiple plastic stents or a single cSEMS, stratified by stricture etiology and with endoscopic reassessment for resolution every 3 months (plastic stents) or every 6 months (cSEMS). Patients were followed up for 12 months after stricture resolution to assess for recurrence.

MAIN OUTCOMES AND MEASURES:

Primary outcome was stricture resolution after no more than 12 months of endoscopic therapy. The sample size was estimated based on the noninferiority of cSEMS to plastic stents, with a noninferiority margin of -15%.

RESULTS:

There were 55 patients in the plastic stent group (mean [SD] age, 57 [11] years; 17 women [31%]) and 57 patients in the cSEMS group (mean [SD] age, 55 [10] years; 19 women [33%]). Compared with plastic stents (41/48, 85.4%), the cSEMS resolution rate was 50 of 54 patients (92.6%), with a rate difference of 7.2% (1-sided 95% CI, -3.0% to ∞; P < .001). Given the prespecified noninferiority margin of -15%, the null hypothesis that cSEMS is less effective than plastic stents was rejected. The mean number of ERCPs to achieve resolution was lower for cSEMS (2.14) vs plastic (3.24; mean difference, 1.10; 95% CI, 0.74 to 1.46; P < .001).

CONCLUSIONS AND RELEVANCE:

Among patients with benign biliary strictures and a bile duct diameter 6 mm or more in whom the covered metallic stent would not overlap the cystic duct, cSEMS were not inferior to multiple plastic stents after 12 months in achieving stricture resolution. Metallic stents should be considered an appropriate option in patients such as these.

TRIAL REGISTRATION:

clinicaltrials.gov Identifier: NCT01221311.

 
Question posée
 
Les stents métalliques couverts sont-ils aussi efficaces que les prothèses plastiques pour traiter les sténoses biliaires bénignes ?
 
Question posée
 
Oui, en moins de séances de CPRE (contrôle à 6 mois vs à 3 mois), et ils sont souvent plus faciles à mettre.
 
Commentaires

Le stent métallique remplace avantageusement les prothèses plastiques car il nécessite moins de procédures, mais le risque de migration est plus important et le canal cystique ne doit pas être couvert par le stent quand la vésicule est en place.

 
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