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©The Author(s) 2026. Published by Baishideng Publishing Group Inc. All rights reserved.
Fully covered metal biliary stents confer a higher risk of post-endoscopic retrograde cholangiopancreatography pancreatitis
Linda Yun Zhang, Dhanashree Tikhe, Apurva Shrigiriwar, George Ermerak, Hsing Hwa Lee, Letisia Sin, Ian Turner, Paul Edwards, David Abi-Hanna, Luke Hourigan, Stuart Kostalas, Milan Bassan
Linda Yun Zhang, Dhanashree Tikhe, George Ermerak, Ian Turner, Paul Edwards, David Abi-Hanna, Milan Bassan, Department of Gastroenterology and Hepatology, Liverpool Hospital, Liverpool 2170, New South Wales, Australia
Linda Yun Zhang, George Ermerak, Milan Bassan, School of Medicine, University of New South Wales, Sydney 2000, New South Wales, Australia
Apurva Shrigiriwar, Department of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD 21231, United States
Hsing Hwa Lee, Luke Hourigan, Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba 4102, Queensland, Australia
Letisia Sin, Stuart Kostalas, Department of Gastroenterology and Hepatology, Port Macquarie Base Hospital, Port Macquarie 2444, New South Wales, Australia
Ian Turner, School of Medicine, Western Sydney University, Sydney 2000, New South Wales, Australia
Luke Hourigan, School of Medicine, University of Queensland, Brisbane 4000, Queensland, Australia
Author contributions: Zhang LY, Tikhe D, Shrigiriwar A, Ermerak G, Lee HH, Sin L, Turner I, Edwards P, Abi-Hanna D, Hourigan L, Kostalas S, and Bassan M contributed to the final approval of the manuscript; Shrigiriwar A, Turner I, Edwards P, Abi-Hanna D, Hourigan L, Kostalas S, and Bassan M contributed to critical revisions of the article for important intellectual content; Zhang LY and Bassan M contributed to the conception and design of the study; Zhang LY, Shrigiriwar A, Tikhe D, Ermerak G, Lee HH, and Sin L contributed to the data collection, analysis, and interpretation of the data; Zhang LY drafted the manuscript.
Institutional review board statement: This study received internal institutional review board approval (No. ETH14056).
Informed consent statement: This retrospective study did not require informed consent.
Conflict-of-interest statement: The authors have no conflicts of interest to declare.
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 that support the findings of this study are not publicly available due to institutional and ethical restrictions related to patient confidentiality.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
https://creativecommons.org/Licenses/by-nc/4.0/ Corresponding author: Linda Yun Zhang, Department of Gastroenterology and Hepatology, Liverpool Hospital, Corner Elizabeth and Goulburn St, Liverpool NSW 2170 Australia, Liv
erpool 2170, New South Wales, Australia.
linda_yun_zhang@hotmail.com
Received: August 8, 2025
Revised: August 29, 2025
Accepted: January 9, 2026
Published online: March 5, 2026
Processing time: 187 Days and 16.8 Hours
BACKGROUND
Biliary fully-covered self-expanding metal stents (FCSEMS) are increasingly used over plastic or uncovered SEMS due to their long-term patency and removability. However, there is concern that transpapillary placement may lead to post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP).
AIM
To assess the rates of PEP with and without the use of FCSEMS for both benign and malignant indications.
METHODS
We performed a multicenter retrospective cohort study involving three Australian tertiary referral centers. Consecutive adults who underwent ERCP for biliary indications between October 2016 and October 2019 were included. The primary endpoint was the rate of PEP. Secondary endpoints included severity of pancreatitis, other procedure- and stent-related adverse events occurring within 90 days.
RESULTS
A total of 3401 ERCPs were performed (54.2% female, mean age 62.9±18.6 years) with an overall PEP rate of 3.15%. On propensity-score matched analysis, FCSEMS was an independent predictor of PEP (odds ratio = 5.49, 95% confidence interval: 2.10-6.99; P = 0.001). FCSEMS had a higher rate of PEP (7.8%) compared with plastic stents (3.4%; P = 0.0015), and patients who did not receive any stents (2.4%; P = 0.001), but was non-significant when compared with uncovered self-expanding metal stents (3.9%; P = 0.12). The rate of PEP following FCSEMS decreased to 6.0% for malignant indications, and further to 3.9% for biliary obstruction due to pancreatic cancer, but did not reach statistical significance.
CONCLUSION
Biliary FCSEMS are associated with a higher risk of PEP compared to no stents or plastic stents, particularly for benign indications.
Core Tip: Biliary fully covered self-expanding metal stents appear to be associated with a higher risk of post-endoscopic retrograde cholangiopancreatography pancreatitis compared with no stents or plastic stents, regardless of the papilla status (i.e. native vs not native). This is particularly the case when fully covered self-expanding metal stents are compared to plastic stents for benign biliary obstruction. Further prospective studies are needed to validate this finding and guide optimal stent selection for patients.
