Double plastic stenting for inoperable malignant biliary stricture among cirrhotic patients as a possible cost-effective treatment: a pilot study Mohamed I. Radwan a , Mohamed H. Emara b , Mariam S. Zaghloul b and Abdallah M.S. Zaghloul a Background and study aim Endoscopic retrograde cholangiopancreatography (ERCP) has evolved as the main therapeutic intervention for hepatobiliary disorders. Palliative stenting for inoperable cases is associated with better morbidity and mortality than surgery. This work aimed at assessing the effect of insertion of two plastic stents in inoperable malignant biliary stricture among cirrhotic patients regarding stent patency, quality of life (QOL), and cost. Patients and methods This multicenter study included 72 cirrhotic patients presented for ERCP with an inoperable malignant biliary stricture. All patients underwent ERCP after preoperative optimization with sphincterotomy, balloon dilatation, and insertion of two plastic stents of 10 Fr. Evaluation included stent patency at 6 months, effect on the QOL using EORTC QLQ-C30 (version 3), adverse events, and the cost. Results Patients included 67% of males and had an age range of 48–88 years (mean: 70 years). In all, 92% of stents were patent at 6 months. Significant improvement in serum total bilirubin and all items of QOL questionnaire at 6 months after the procedure was reported. Cholangitis and pancreatitis were reported in 25 and 8% of cases, respectively. The cost of insertion of two plastic stents and the daily cost of the procedure regarding the effect on QOL were low. Conclusion Double plastic stenting of the common bile duct seems effective at 6 months of follow-up among cirrhotic patients with inoperable malignant biliary obstruction. Furthermore, it seems also valuable in improving laboratory findings and QOL among those patients with an acceptable cost. Eur J Gastroenterol Hepatol 31:1057–1063 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. Introduction Endoscopic retrograde cholangiopancreatography (ERCP) has evolved as a major therapeutic intervention for biliary and pancreatic disorders. Among cirrhotic patients, ERCP is increasingly performed owing to both better improve- ments in preoperative preparation and also wider avail- ability of ERCP theaters, although it carries a risk of complications, particularly bleeding diathesis [1]. Surgery carries a high risk of morbidity and mortality among cirrhotic patients and consequently alternatives including ERCP are preferable than surgery [2,3]. Baron [4] states that surgery offers the only hope for cure in patients with malignant biliary obstruction, but unfortu- nately patients usually present late in an inoperable state in their course, have either locally extensive or metastatic dis- ease, and have an extremely grim prognosis; therefore, pal- liative treatment, aimed at both relieving jaundice and improving quality of life (QOL) by endoscopic biliary stenting is usually the treatment option of choice. Management of malignant biliary obstruction by biliary stenting is safe and effectively reestablishes bile flow, alleviates jaundice and pruritus, and may improve QOL [5]. Insertion of the single plastic stent is the usual practice, with its main drawbacks being early stent obstruction and high incidence of cholangitis with the need for stent exchange and consequently increasing the cost. The introduction of self-expendable metallic stents (SEMS) with wider diameter solved the pro- blem of early stent obstruction but at the expense of the cost [3,6]. In low-resource communities, particularly with the lack of proper health insurance facilities, the cost will be a major issue especially when life expectancy is short. Consequently, we planned for this study to evaluate the efficacy, QOL, and cost-effectiveness of double plastic stenting to alleviate inoperable malignant biliary obstruc- tion among Egyptian cirrhotic patients. Patients and methods This multicenter interventional study was conducted in the ERCP units of Tropical Medicine Department, Zagazig University Hospitals, Egypt and Hepatology, Gastroenterology and Infectious Diseases Department, Kafrelshiekh University Hospitals, Egypt, during the period from August 2017 to August 2018. Inclusion criteria All cirrhotic patients of both sexes and any age with inoperable/unresectable malignant biliary stricture a Department of Tropical Medicine, Faculty of Medicine, Zagazig University, Zagazig and b Department of Hepatology, Gastroenetrology and Infectious Diseases, Faculty of Medicine, Kafrelsheikh University, Kafrelsheikh, Egypt Correspondence to Mohamed H. Emara, MD, Department of Hepatology, Gastroenetrology and Infectious Diseases, Faculty of Medicine, Kafrelsheikh University, Kafrelsheikh 33516, Egypt Tel: + 20 100 272 4482; fax: + 20 473 632 344; e-mail: emara_20007@yahoo.com Received 13 February 2019 Accepted 26 March 2019 European Journal of Gastroenterology & Hepatology 2019, 31:1057–1063 Keywords: cirrhosis, cost, double stent, endoscopic retrograde cholangiopancreatography, quality of life ’ Original article 0954-691X Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/MEG.0000000000001425 1057 Copyright r 2019 Wolters Kluwer Health, Inc. All rights reserved.