Balli E, Kirmaci MB, Shahryar GR, Yilmaz S. Fully covered metal vs plastic stents after failed endoscopic retrograde cholangiopancreatography: Impact on residual stones. World J Gastrointest Surg 2026; 18(6): 120524 [DOI: 10.4240/wjgs.120524]
Corresponding Author of This Article
Emre Balli, Assistant Professor, Department of General Surgery, Afyonkarahisar Health Sciences University, Dörtyol Mah. 2078 Sok. No. 3/4, Afyonkarahisar 03100, Türkiye. balliemre_88@hotmail.com
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Surgery
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Balli E, Kirmaci MB, Shahryar GR, Yilmaz S. Fully covered metal vs plastic stents after failed endoscopic retrograde cholangiopancreatography: Impact on residual stones. World J Gastrointest Surg 2026; 18(6): 120524 [DOI: 10.4240/wjgs.120524]
World J Gastrointest Surg. Jun 27, 2026; 18(6): 120524 Published online Jun 27, 2026. doi: 10.4240/wjgs.120524
Fully covered metal vs plastic stents after failed endoscopic retrograde cholangiopancreatography: Impact on residual stones
Emre Balli, Mehlika Bilgi Kirmaci, Ghulam Reza Shahryar, Sezgin Yilmaz
Emre Balli, Mehlika Bilgi Kirmaci, Ghulam Reza Shahryar, Sezgin Yilmaz, Department of General Surgery, Afyonkarahisar Health Sciences University, Afyonkarahisar 03100, Türkiye
Author contributions: Balli E and Bilgi Kirmaci M designed the study; Shahryar GR recruited the participants and collected the data; Yilmaz S performed the statistical analysis and interpreted the data; Balli E and Yilmaz S drafted the initial manuscript; all authors critically reviewed and approved the final version of the manuscript.
Institutional review board statement: This study was approved by the Non-Interventional Clinical Research Ethics Committee of Afyonkarahisar Health Sciences University.
Informed consent statement: Given the retrospective nature of this study and the use of de-identified data, the requirement for informed consent was waived by the Ethics Committee of the Afyonkarahisar University of Health Sciences.
Conflict-of-interest statement: The authors report no relevant conflicts of interest for this article.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Data sharing statement: The data in this study were obtained from the Afyonkarahisar Healt Sciences Hospital database, where restrictions may be applied, as information could compromise the privacy of research participants. The datasets may be requested from the corresponding author.
Corresponding author: Emre Balli, Assistant Professor, Department of General Surgery, Afyonkarahisar Health Sciences University, Dörtyol Mah. 2078 Sok. No. 3/4, Afyonkarahisar 03100, Türkiye. balliemre_88@hotmail.com
Received: March 1, 2026 Revised: March 12, 2026 Accepted: March 25, 2026 Published online: June 27, 2026 Processing time: 113 Days and 13.8 Hours
Abstract
BACKGROUND
Management of difficult bile duct stones (DBDS) remains challenging when complete ductal clearance cannot be achieved during the initial endoscopic retrograde cholangiopancreatography (ERCP). Temporary biliary stenting is commonly used in this setting; however, the optimal stent type remains debated.
AIM
To evaluate outcomes of plastic stents (PS) vs fully covered self-expandable metal stents (cSEMS) after unsuccessful bile duct stone extraction.
METHODS
This retrospective single-center study included patients who underwent ERCP with PS or cSEMS biliary stent placement between January 2020 and May 2025 due to complex choledocholithiasis following unsuccessful initial ductal clearance. The primary outcome was presence of residual stones at second-look ERCP. Secondary outcomes included reintervention rates and post-ERCP complications. To reduce selection bias, 1:1 propensity score matching (PSM) was performed for age, stone size, and stone number. Multivariate logistic regression was used to identify independent predictors of residual stones.
RESULTS
Seventy-seven patients were included (47 PS and 30 cSEMS). After PSM, 48 matched patients (24 per group) were analyzed. Residual stones at second ERCP were more frequent in the PS group than in the cSEMS group before (29.8% vs 10.0%, P = 0.036) and after (25.0% vs 8.3%, P = 0.041) matching. Re-stenting was required in 17.0% of PS patients, whereas none of the cSEMS patients required repeat stenting (P = 0.015 before matching and P = 0.020 after matching). Rates of post-ERCP pancreatitis and bleeding were similar between the groups. Multivariate analysis showed that cSEMS placement independently reduced the risk of residual stones (OR = 0.31, 95%CI: 0.11-0.98, P = 0.039), whereas larger stone size predicted treatment failure (OR = 1.73, 95%CI: 1.44-3.17, P = 0.041).
CONCLUSION
In patients with DBDS and incomplete initial ductal clearance, temporary cSEMS placement achieved higher bile duct clearance and lower reintervention rates compared with PS, without increasing complications. Prospective randomized studies are needed to confirm these findings.
Core Tip: This study compared the clinical efficacy of fully covered self-expandable metal stents and plastic stents in patients with difficult bile duct stones following unsuccessful initial endoscopic retrograde cholangiopancreatography (ERCP). In this retrospective single-center cohort, propensity score matching minimized selection bias and ensured baseline comparability. Residual stone rates at second-look ERCP were lower in the metal stent group. Re-intervention and repeat stenting were also reduced, while complication rates were similar between groups. Multivariate analysis identified metal stent placement as an independent predictor of ductal clearance. Temporary metal stent placement appears safe and clinically beneficial.
