Metallic vs plastic stents for benign biliary strictures

To the Editor Dr Coté and colleagues1 conducted a randomized trial that showed that fully covered metallic stents were not inferior to multiple plastic stents in achieving resolution of certain types of benign biliary strictures. Multiple progressive plastic stenting to treat postoperative bile duct strictures was introduced in 20012 and has been widely adopted worldwide.3,4 The progressive stretching of the fibrotic biliary stricture with an increasing number of plastic stents maintains good results after more than 10 years of follow-up.5 The main limitation of this method is the need for repeated endoscopic interventions to replace the stents and increase their number, which leads to higher costs and requires good adherence from patients. Removable fully covered self-expanding metallic stents represent an appealing alternative because only 2 endoscopic retrograde cholangiopancreatography procedures, one to implant the stent and one to remove it, are theoretically required. However, only a minority of patients with benign biliary strictures are good candidates for metallic stenting. Most patients with benign biliary strictures have a postcholecystectomy injury, which is seldom amenable to metallic stenting for 2 reasons: the stricture is often located close to the main hepatic confluence, and the bile duct below the stricture is usually of normal caliber. Only 4 of 112 patients (3.6%) randomized in the study by Coté and colleagues1 had “other postoperative injuries,” whereas the majority had anastomotic strictures after orthotopic liver transplantation and chronic pancreatitis. The study by Coté and colleagues1 therefore concerned only a limited, well-selected subset of patients with benign biliary strictures