Surgical Endoscopy

, Volume 33, Issue 12, pp 4109–4115 | Cite as

Impact of infected stent removal on recurrent cholangitis with time-to-event analysis

  • Pichamol Jirapinyo
  • Mohd Amer AlSamman
  • Christopher C. ThompsonEmail author



The optimal approach at treating infected biliary stents at the time of cholangitis remains unknown. This study aims to compare the efficacy of stent exchange versus stent sweeping/stent-in-stent approaches at treating cholangitis.


The study was a retrospective cohort study. Patients with biliary stents and cholangitis were included. Outcomes were rate of recurrent cholangitis and time to recurrent cholangitis in those whose stents were left in place (stent sweeping and stent-in-stent) compared to those whose stents were removed (stent exchange). Primary analysis included patients with metal biliary stents only. Secondary analysis included those with metal and plastic biliary stents.


A total of 182 patients (age 64 ± 12;89 F) with a metal biliary stent(s) at index cholangitis were included. Of these, 40 (22%) had stents removed, i.e., stent exchange. The remaining 142 (78%) did not have stent removal (97 with stent-in-stent and 45 with stent sweeping). Recurrent cholangitis occurred in 22.5% and 42.3% in the stent removal and non-removal groups, respectively (p = 0.02). Stent removal remained a negative predictor of recurrent cholangitis after controlling for age, sex, history of diabetes, and chemotherapy (OR 0.39, p = 0.03). Median time from index cholangitis to recurrent cholangitis was shorter for patients whose stents were not removed compared to those whose stents were removed (182 vs 450 days, p = 0.011). On Cox regression model, stent removal remained a negative predictor of recurrent cholangitis after controlling for age, sex, history of diabetes, and chemotherapy (HR 0.41, p = 0.01). The findings persisted in the secondary analysis including both metal and plastic biliary stents (303 patients).


Biliary stent removal with stent exchange at the time of cholangitis appears to be more effective at preventing recurrent cholangitis than leaving an infected stent in the biliary system.


Cholangitis Biliary stent Stent occlusion Biofilm Stent exchange Sweeping Stent-in-stent 


Compliance with ethical standards


Drs. Pichamol Jirapinyo, Mohd AlSamman, and Christopher Thompson have no conflicts of interest or financial ties to disclose.


  1. 1.
    Charcot M (1877) Comparison avec la fievre uroseptique. Lecons sur les maladies du foie des voies biliares et des reins. Paris: Bourneville et Sevestre. De la fievre hepatique symptomatique; pp 176–85Google Scholar
  2. 2.
    Reynolds BM, Dargan EL (1959) Acute obstructive cholangitis; a distinct clinical syndrome. Ann Surg 150(2):299–303CrossRefGoogle Scholar
  3. 3.
    Kimura Y, Takada T, Kawarada Y, Nimura Y, Hirata K, Sekimoto M, Yoshida M, Mayumi T, Wada K, Miura F, Yasuda H, Yamashita Y, Nagino M, Hirota M, Tanaka A, Tsuyuguchi T, Strasberg SM, Gadacz TR (2007) Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 14(1):15–26CrossRefGoogle Scholar
  4. 4.
    Gigot JF, Leese T, Dereme T, Coutinho J, Castaing D, Bismuth H (1989) Acute cholangitis: multivariate analysis of risk factors. Ann Surg 209:435–438. CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Saharia PC, Cameron JL (1976) Clinical management of acute cholangitis. Surg Gynecol Obstet 142:369–372PubMedGoogle Scholar
  6. 6.
    Thompson JE Jr, Pitt HA, Doty JE, Coleman J, Irving C (1990) Broad spectrum penicillin as an adequate therapy for acute cholangitis. Surg Gynecol Obstet 171:275–282PubMedGoogle Scholar
  7. 7.
    Basoli A, Schietroma M, De Santis A, Colella A, Fiocca F, Speranza V (1986) Acute cholangitis: diagnostic and therapeutic problems. Ital J Surg Sci 16:261–267PubMedGoogle Scholar
  8. 8.
    Huibregtse K, Carr-Locke DL, Cremer M et al (1992) Biliary stent occlusion—a problem solved with self-expanding metal stents? European Wallstent Study Group. Endoscopy 24(5):391–394CrossRefGoogle Scholar
  9. 9.
    Knyrim K, Wagner HJ, Pausch J et al (1993) A prospective, randomized, controlled trial of metal stents for malignant obstruction of the common bile duct. Endoscopy 25(3):207–212CrossRefGoogle Scholar
  10. 10.
    Kiriyama S, Takada T, Strasberg SM et al (2012) New diagnostic criteria and severity assessment of acute cholangitis in revised Tokyo Guidelines. J Hepatobiliary Pancreat Sci 19(5):548–556CrossRefGoogle Scholar
  11. 11.
    Miura F, Takada T, Stransberg SM et al (2013) TG13 flowchart for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci 20:47–54CrossRefGoogle Scholar
  12. 12.
    Ridtitid W, Rerknimitr R, Janchai A et al (2010) Outcome of second interventions for occluded metallic stents in patients with malignant biliary obstruction. Surg Endosc 42:2216–2220CrossRefGoogle Scholar
  13. 13.
    Togawa O, Kawabe T, Isayama H et al (2008) Management of occluded uncovered metallic stents in patients with malignant distal biliary obstructions using covered metallic stents. J Clin Gastroenterol 42:546–549CrossRefGoogle Scholar
  14. 14.
    Bueno JT, Gerdes H, Kurtz RC (2003) Endoscopic management of occluded biliary Wallstents: a cancer center experience. Gastrointest Endosc 58:879–884CrossRefGoogle Scholar
  15. 15.
    Rogant JN, Jain D, Siddiqui UD et al (2008) Analysis of endoscopic management of occluded metal biliary stents at a single tertiary care center. Gastrointest Endosc 68:676–682CrossRefGoogle Scholar
  16. 16.
    Tham TC, Carr-Locke DL, Vandervoort J et al (1998) Management of occluded biliary Wallstents. Gut 42:703–707CrossRefGoogle Scholar
  17. 17.
    Yoon WJ, Ryu JK, Lee JW et al (2010) Endoscopic management of occluded metal biliary stents: metal versus 10F plastic stents. World J Gastroenterol 14:5347–5352CrossRefGoogle Scholar
  18. 18.
    Libby ED, Leung JW (1996) Prevention of biliary stent clogging: a clinical review. Am J Gastroenterol 91:1301–1308PubMedGoogle Scholar
  19. 19.
    Leung JW, Liu Y, Chan RC et al (2000) Early attachment of anaerobic bacteria may play an important role in biliary stent blockage. Gastrointest Endosc 52:725–729CrossRefGoogle Scholar
  20. 20.
    van Berkel AM, van Marle J, Groen AK et al (2005) Mechanisms of biliary stent clogging: confocal laser scanning and scanning electron microscopy. Endoscopy 37:729–734CrossRefGoogle Scholar
  21. 21.
    Donelli G, Guaglianone E, Di Rosa R et al (2007) Plastic biliary stent occlusion: factors involved and possible preventive approaches. Clin Med Res 5:53–60CrossRefGoogle Scholar
  22. 22.
    Moesch C, Sautereau D, Cessot F et al (1991) Physicochemical and bacteriological analysis of the contents of occluded biliary endoprostheses. Hepatology 13:1142–1146CrossRefGoogle Scholar
  23. 23.
    An YH, Friedman RJ (1998) Concise review of mechanisms of bacterial adhesion to biomaterial surfaces. J BiomedMaterRes 43:338–348Google Scholar
  24. 24.
    Yu JL, Anderson R, Wang LQ (1995) Fibronectin on the surface of biliary drain materials: a role in bacterial adherence. J Surg Res 59:596–600CrossRefGoogle Scholar
  25. 25.
    Landau O, Kott I, Deutsch AA et al (1992) Multifactorial analysis of septic bile and septic complications in biliary surgery. World J Surg 16:962–964CrossRefGoogle Scholar
  26. 26.
    Hashimoto J, Morizane C, Kondo S et al (2011) Incidence and risk factors for cholangitis during systemic chemotherapy among patients with advanced biliary tract cancer. J Clin Oncol 29:313CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Division of Gastroenterology, Hepatology and EndoscopyBrigham and Women’s HospitalBostonUSA
  2. 2.Harvard Medical SchoolBostonUSA
  3. 3.Alpert Medical School of Brown UniversityProvidenceUSA

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