全覆膜可取出金属支架治疗难治性食管良性狭窄

目的评价全覆膜可取出金属支架治疗难治性食管良性狭窄的疗效和安全性。方法选择经内镜扩张治疗失败的难治性食管良性狭窄病例6例，其中化学性烧伤3例，食管胃吻合口狭窄2例，吻合口狭窄、金属支架置入术再再狭窄1例，按病例不同情况设计全覆膜可取出金属支架的形状，置入食管狭窄段，定期观察症状的变化、支架两端黏膜增生情况及支架取出后症状的变化情况。结果所有病例均成功置入支架，支架置入后吞咽困难症状均得到持续改善，能进食软食。支架置入3～6个月后均经内镜成功取出，无1例发生支架端口黏膜增生、支架再狭窄：其中4例支架取出后随访2～12个月，症状持续改善，无需阿治疗；另2例发生支架移位，支架取出后1个月内再次出现吞咽困难。1例支架置入术后出现胸骨后疼痛，无其它并发症发生．结论个体化设计的全覆膜可取出金属支架足治疗难治性食管良性狭窄的一种安全、有效的方法。     

全覆膜与非覆膜金属支架治疗胆道恶性梗阻随机对照研究

目的 比较全覆膜金属支架与非覆膜金属支架治疗胆道恶性梗阻的有效性和安全性.方法 2010年10月至2012年8月无法手术根治性切除胆道恶性梗阻病例,随机分为两组,A组置入全覆膜金属支架,B组置入非覆膜金属支架,观察治疗效果及并发症情况.结果 共入组81例患者,其中A组41例,B组40例,两组均成功置入支架,达到有效引流目的.A组支架开放中位时间182.5 d,B组支架开放中位时间195.0 d,两组间支架开放时间差异无统计学意义(P=0.616).A组发生并发症3例(7.3％),B组发生4例(10％).结论 全覆膜金属支架与非覆膜金属支架治疗胆道恶性梗阻均安全有效,通畅时间相似.     

可回收支架用于良性气管狭窄患者24例效果观察

目的探讨可回收全覆膜金属支架用于良性气管狭窄的临床效果。方法对24例良性气管狭窄患者于透视引导下置入可回收全覆膜金属支架,支架完全覆盖狭窄段,两端分别超出狭窄段10～15mm。术后根据CT、气管镜检查和临床症状的缓解情况于4—8个月取出支架,观察支架置入前和取出后气管直径、气促评分、第一秒用力呼气量（FEV1）,统计并发症（分泌物滞留、肉芽组织增生、支架移位及咳出）发生情况。结果24例患者共置入31个气管支架,置入后支架膨胀完全,患者呼吸道梗阻症状立即缓解。支架取出后气管直径及FEV1明显高于、气促评分明显低于置人前（P均〈0．05）,临床症状均明显缓解。3例复发性多软骨炎患者支架未取出,出现分泌物滞留24例,肉芽组织增生21例,支架移位及咳出3例。结论可回收全覆膜金属支架用于良性气管狭窄效果确切,且较为安全。     

全覆膜自膨式金属支架治疗难治性胰管良性狭窄的长期疗效观察（含视频）

目的　评价全覆膜自膨式金属支架治疗难治性胰管良性狭窄的安全性和长期疗效。方法　收集南京鼓楼医院消化内镜中心2013年3月—2020年7月经全覆膜自膨式金属支架治疗的18例难治性胰管良性狭窄患者资料进行回顾性分析。主要观察指标包括技术成功率、临床成功率、全覆膜自膨式金属支架副作用及长期疗效。结果　18例患者均成功置入全覆膜自膨式金属支架,技术成功率100.0%（18/18）。18例患者支架置入后的腹痛评分明显低于置入前［2.00（1.75,3.00）分比6.00（5.00,7.00）分,Z=-3.572,P<0.001］。支架置入后疼痛评分较置入前减少> 50%的有15例,临床成功率83.3%（15/18）。支架置入后,出现不能忍受的腹痛3例,支架诱导的新狭窄2例,支架远端移位2例。所有患者成功拔除支架,支架置入时间137.5（59.0,417.0）d。拔除支架后狭窄上游扩张胰管直径［9.1（6.7,14.1）mm］比支架置入前［11.0（7.6,16.2）mm］明显减少（Z=10.508,P<0.001）。长期随访14例患者,随访时间37~1 246 d,10例患者保持无临床症状,4例复发。结论　全覆膜自膨式金属支架治疗难治性胰管良性狭窄安全有效且可维持长期疗效。     

全覆膜自膨式金属支架治疗难治性胰管良性狭窄的长期疗效观察(含视频)

目的评价全覆膜自膨式金属支架治疗难治性胰管良性狭窄的安全性和长期疗效。方法收集南京鼓楼医院消化内镜中心2013年3月—2020年7月经全覆膜自膨式金属支架治疗的18例难治性胰管良性狭窄患者资料进行回顾性分析。主要观察指标包括技术成功率、临床成功率、全覆膜自膨式金属支架副作用及长期疗效。结果 18例患者均成功置入全覆膜自膨式金属支架, 技术成功率100.0%(18/18)。18例患者支架置入后的腹痛评分明显低于置入前[2.00(1.75, 3.00)分比6.00(5.00, 7.00)分, Z=-3.572, P<0.001]。支架置入后疼痛评分较置入前减少> 50%的有15例, 临床成功率83.3%(15/18)。支架置入后, 出现不能忍受的腹痛3例, 支架诱导的新狭窄2例, 支架远端移位2例。所有患者成功拔除支架, 支架置入时间137.5(59.0, 417.0)d。拔除支架后狭窄上游扩张胰管直径[9.1(6.7, 14.1)mm]比支架置入前[11.0(7.6, 16.2)mm]明显减少(Z=10.508, P<0.001)。长期随访14例患者, 随访时间37～1...     

内镜支架置入新技术治疗幽门良性狭窄的初步观察（含视频）

2017年6月—2019年9月,5例良性重度幽门狭窄患者在郑州大学第一附属医院接受了内镜下全覆膜支架置入新技术治疗,5例均成功完成幽门处全覆膜支架置入,无并发症发生,术后行上消化道造影显示支架位置良好、造影剂通过顺利。5例患者于术后1～3 d开始进流食,进食后均无呕吐、腹痛、腹泻等症状出现,随访期间均有不同程度的体重增加,营养状态获得明显改善。4例于术后3～4个月行支架取出术;余1例于术后3个月发现支架移位至胃内,取出支架后观察幽门口略狭窄,行球囊扩张术+黏膜切开术。随后5例继续随访3个月,均无症状反复及再狭窄。以上结果初步证实,内镜下全覆膜支架置入新技术治疗良性幽门狭窄安全、有效。     

叠放法取出胆道非覆膜金属支架的初步临床应用

金属支架因其开通时间长的优势已用于胆道良恶性狭窄的治疗[1].临床工作中经常遇到胆道良性病变置入非覆膜金属支架取出困难病例,国外已有通过叠放法取出胆道非覆膜金属支架的报道[2-3],国内尚无类似研究.     

应用金属支架治疗儿童难治性食管良性狭窄的临床价值

目的:探讨可回收全覆膜金属支架治疗儿童难治性食管良性狭窄的安全性和疗效.方法:应用可回收全覆膜金属支架治疗7例难治性食管良性狭窄患儿,其中术后吻合口狭窄5例,化学烧伤性狭窄2例.支架置入术后定期随访,观察患儿吞咽困难改善程度、狭窄口直径、并发症等.结果:7例患儿均成功行支架置入术,1例患儿术中并发皮下气肿.支架取出后随访3-27 mo,所有患儿吞咽困难症状显著改善,食管狭窄段口由2-5 mm扩大至12-13 mm.其中1例并发肉芽组织轻微增生,2例发生支架移位.结论:可回收全覆膜金属支架治疗儿童难治性良性食管狭窄安全有效,其长期疗效仍有待于进一步研究.     

覆膜金属支架治疗食管癌食管气管瘘21例疗效分析

目的探讨胃镜置入覆膜金属支架治疗食管癌食管气管瘘的临床疗效。方法 2005～2010年本院病理确诊的食管癌患者21例,经胃镜或食管造影证实合并食管-气管瘘,根据食管狭窄的程度、位置、长度及瘘口部位,确定支架长度和支架放置位置,随后行食管狭窄扩张术及覆膜支架置入术。结果 21例患者均成功置入覆膜金属支架。患者呛咳、吞咽梗阻及肺部感染等症状明显缓解,术后随访平均存活9个月(2～14个月)。结论覆膜金属支架置入术是治疗食管癌食管气管瘘的一种安全有效地方法,能明显缓解患者症状,延长患者生存时间,提高患者生活质量。     

新型超覆膜金属支架治疗难治性食管胃吻合口狭窄的研究

目的评价新型超覆膜金属支架治疗难治性食管胃吻合口狭窄的疗效和安全性。方法选择经内镜下反复扩张效果较差的22例难治性食管胃吻合口良性狭窄的患者,内镜下置入直径为16 mm或18 mm新型超覆膜金属支架,对比支架置入前后患者吞咽困难改善情况、体力状况评分,同时观察在支架置入3个月期间,胸痛、支架移位、肉芽组织增生、溃疡及出血等支架相关并发症的发生情况。结果 22例患者均成功置入支架,在支架置入一周后患者吞咽困难情况明显改善(P0.05),吞咽困难缓解率为100%,患者胸痛评分较前明显提高(P0.05)。在支架留置期间,移位发生率为13.6%(3/22),肉芽组织增生发生率为22.7%(5/22),溃疡发生率为18.2%(4/22),出血倾向发生率为4.55%(1/22),所有患者在支架留置3个月后均顺利取出,无严重并发症发生。支架取出后再狭窄发生率为13.6%(3/22)。结论新型超覆膜食管支架治疗难治性食管胃吻合口狭窄是安全有效的,支架置入期间应密切随访,预防并发症。     

Side-by-side placement of bilateral endoscopic metal stents for the treatment of postoperative biliary stricture

Postoperative biliary strictures are usually complications of cholecystectomy. Endoscopic plastic stent prosthesis is generally undertaken for treating benign biliary strictures. Recently, fully covered metal stents have been shown to be effective for treating benign distal biliary strictures. We present the case of a 53-year-old woman with liver injury in which imaging studies showed a common hepatic duct stricture. Endoscopic retrograde cholangiopancreatography also confirmed the presence of a common hepatic duct stricture. Temporally fully covered metal stents with dilated diameters of 6 mm were placed in a side-by-side fashion in the left and right hepatic ducts, respectively. We removed the stents 2 months after their placement. Subsequent cholangiography revealed an improvement in the biliary strictures. Although we were apprehensive about the fully covered metal stents obstructing the biliary side branches, we noted that careful placement of the bilateral metal stents did not cause any complications. Side-by-side deployment of bilateral endoscopic fully covered metal stents can be one of the safe and effective therapies for postoperative biliary stricture.     

Evaluation of fully covered self-expanding metal stents in benign biliary strictures and bile leaks

AIM: To investigate the use of fully covered metal stents in benign biliary strictures (BBS) and bile leaks.METHODS: We studied 17 patients, at Harbor-UCLA Medical center (Los Angeles), with BBS (n = 12) and bile leaks (n = 5) from July 2007 to February 2012 that had received placement of fully covered self-expanding metal stents (FCSEMs). Fourteen patients had endoscopic placement of VIABIL^® (Conmed, Utica, New York, United States) stents and three had Wallflex^® (Boston Scientific, Mass) stents. FCSEMS were 8 mm or 10 mm in diameter and 4 cm to 10 cm in length. Patients were followed at regular intervals to evaluate for symptoms and liver function tests. FCSEMS were removed after 4 or more weeks. Resolution of BBS and leak was documented cholangiographically following stent removal. Stent patency can be defined as adequate bile and contrast flow from the stent and into the ampulla during endoscopic retrograde cholangiopancreatography (ERCP) without clinical signs and/or symptoms of biliary obstruction. Criterion for bile leak resolution at ERCP is defined as absence of contrast extravasation from the common bile duct, cystic duct remanent, or gall bladder fossa. Rate of complications such as migration, and in-stent occlusion were recorded. Failure of endoscopic therapy was defined as persistent biliary stenosis or continuous biliary leakage after 12 mo of stent placement.RESULTS: All 17 patients underwent successful FCSEMS placement and removal. Etiologies of BBS included: cholecystectomies (n = 8), cholelithiasis (n = 2), hepatic artery compression (n = 1), pancreatitis (n = 2), and Whipple procedure (n = 1). All bile leaks occurred following cholecystectomy. The anatomic location of BBS varied: distal common bile duct (n = 7), common hepatic duct (n = 1), hepaticojejunal anastomosis (n = 2), right intrahepatic duct (n = 1), and choledochoduodenal anastomatic junction (n = 1). All bile leaks were found to be at the cystic duct. Twelve of 17 patients had failed prior stent placement or exchange. Resolution of the biliary strictures and bile leaks was achieved in 16 of 17 patients (94%). The overall median stent time was 63 d (range 27-251 d). The median stent time for the BBS group and bile leak group was 62 ± 58 d (range 27-199 d) and 92 ± 81 d (range 48-251 d), respectively. All 17 patients underwent successful FCSEMS removal. Long term follow-up was obtained for a median of 575 d (range 28-1435 d). Complications occurred in 5 of 17 patients (29%) and included: migration (n = 2), stent clogging (n = 1), cholangitis (n = 1), and sepsis with hepatic abscess (n = 1).CONCLUSION: Placement of fully covered self-expanding metal stents may be used in the management of benign biliary strictures and bile leaks with a low rate of complications.     

An Update to Hepatobiliary Stents

Endoscopic stent placement is a common primary management therapy for benign and malignant biliary strictures. However, continuous use of stents is limited by occlusion and migration. Stent technology has evolved significantly over the past two decades to reduce these problems. The purpose of this article is to review current guidelines in managing malignant and benign biliary obstructions, current endoscopic techniques for stent placement, and emerging stent technology. What began as a simple plastic stent technology has evolved significantly to include uncovered, partially covered, and fully covered self-expanding metal stents (SEMS) as well as magnetic, bioabsorbable, drug-eluting, and antireflux stents.¹     

Fully covered metal biliary stents: A review of the literature

Fully covered self-expandable metal stents (FCSEMS) represent the latest advancement of metal biliary stents used to endoscopically treat a variety of obstructive biliary pathology. A large stent diameter and synthetic covering over the tubular mesh prolong stent patency and reduce risk for tissue hyperplasia and tumor ingrowth. Additionally, FCSEMS can be easily removed. All these features address issues faced by plastic and uncovered metal stents. The purpose of this paper is to comprehensively review the application of FCSEMS in benign and malignant biliary strictures, biliary leak, and post-sphincterotomy bleeding.     

Fully covered self-expandable metal stents for treatment of malignant and benign biliary strictures

AIM:To present a series of covered self-expandable metal stents(CSEMS) placed for different indications and to evaluate the effectiveness,complications and extractability of these devices.METHODS:We therefore retrospectively reviewed the courses of patients who received CSEMS due to malignant as well as benign biliary strictures and postsphincterotomy bleeding in our endoscopic unit between January 2010 and October 2011.RESULTS:Twenty-six patients received 28 stents due to different indications(20 stents due to malignant biliary strictures,six stents due to benign biliary strictures and two stents due to post-sphincterotomy bleeding).Biliary obstruction was relieved in all cases,regardless of the underlying cause.Hemostasis could be achieved in the two patients who received the stents for this purpose.Complications occurred in five patients(18%).Two patients(7%) developed cholecystitis,stents dislocated/migrated in other two patients(7%),and in one patient(3.6%) stent occlusion was documented during the study period.Seven stents were extracted endoscopically.Removal of stents was easily possible in all cases in which it was desired using standard forceps.Twelve patients underwent surgery with pylorus preserving duodenopancreatectomy.In all patients stents could be removed during the operation without difficulties.CONCLUSION:Despite the higher costs of these devices,fully covered self-expanding metal stents may be suitable to relief biliary obstruction due to bile duct stenosis,regardless of the underlying cause.CSEMS may also represent an effective treatment strategy of severe post-sphincterotomy bleeding,not controlled by other measures.     

Endoscopic treatment for biliary stricture secondary to chronic pancreatitis

The causes of benign biliary stricture include chronic pancreatitis, primary/immunoglobulin G4-related sclerosing cholangitis and complications of surgical procedures. Biliary stricture due to fibrosis as a result of inflammation is sometimes encountered in patients with chronic pancreatitis. Frey's procedure, which can provide pancreatic duct drainage with decompression of biliary stricture, can be an initial treatment for chronic pancreatitis with pancreatic and bile duct strictures with upstream dilation. When patients are high-risk surgical candidates or hesitate to undergo surgery, endoscopic treatment appears to be a potential second-line therapy. Placement of multiple plastic stents is currently considered to be the best choice as endoscopic treatment for biliary stricture due to chronic pancreatitis. Temporary placement with a fully covered metal stent has become an attractive option due to the lesser number of endoscopic retrograde cholangiopancreatography (ERCP) sessions and its large diameter. Further clinical trials comparing multiple placement of plastic stents with placement of a covered metal stent for biliary stricture secondary to chronic pancreatitis are awaited.     

Percutaneous Transhepatic Treatment Using Retrievable Covered Stents in Patients with Benign Biliary Strictures: Mid-term Outcomes in 68 Patients

Background

Percutaneous balloon dilation of benign biliary stricture has been the most widely used alternative to endoscopic treatment; however, the rate of recurrence has varied from 15 to 44 %. Recently, several investigators have reported that percutaneous transhepatic placement of retrievable covered stents is feasible for the treatment of benign biliary strictures. However, these studies had only a small number of patients and had short follow-up periods.

Aim

The purpose of this study was to investigate the mid-term outcomes of a retrievable covered stent for treatment of benign biliary strictures.

Methods

We retrospectively assessed 68 patients who underwent percutaneous transhepatic placement and removal of a retrievable covered stent between March 2007 and November 2012, for treatment of benign biliary strictures. Forty-two patients had not previously undergone interventional treatment, whereas 26 had recurrent or refractory strictures despite previous percutaneous procedures.

Results

Placement of the retrievable covered stents was technically successful in all patients. Stent migration occurred in 11 (16.2 %) patients. The mean indwelling period of drainage catheter and stent were 5.8 months (range, 3–22.5 months) and 3 months (range, 2–6.5 months), respectively. Clinical success was achieved in 59 (86.8 %) patients. During the mean follow-up of 36 months (range, 8.5–65 months), 12 (20 %) of 60 patients had recurrence of clinically significant strictures. The primary patency rates at 1, 2, 3, 4, and 5 years were 91, 89, 76, 68, and 68 %, respectively.

Conclusion

Mid-term outcomes suggested that percutaneous treatment of benign biliary strictures using a retrievable covered stent was a clinically effective method.     

Removal of an embedded "covered" biliary stent by the "stent-in-stent" technique

A 46-year-old man was admitted with obstructive jaundice and cross-sectional imaging with computed tomography suggested distal biliary obstruction.A distal common bile duct stricture was found at endoscopic retrograde cholangiopancreatography(ERCP)and cytology was benign.A 6 cm fully covered self-expanding metal stent(SEMS)was inserted across the stricture to optimize biliary drainage.However,the SEMS could not be removed at repeat ERCP a few months later.A further fully covered SEMS was inserted within the existing stent to enable extraction and both stents were retrieved successfully a few weeks later.Fully covered biliary(SEMS)are used to treat benign biliary strictures.This is the first reported case of inability to remove a fully-covered biliary SEMS.Possible reasons for this include tissue hyperplasia and consequent overgrowth into the stent proximally,or chemical or mechanical damage to the polymer covering of the stent.Application of the stent-in-stent technique allowed successful retrieval of the initial stent.     

Role of endoscopic retrograde cholangiopancreatography in the management of benign biliary strictures: What's new?

Benign biliary strictures comprise a heterogeneous group of diseases. The most common strictures amenable to endoscopic treatment are post-cholecystectomy, post-liver transplantation, related to primary sclerosing cholangitis and to chronic pancreatitis. Endoscopic treatment of benign biliary strictures is widely used as first line therapy, since it is effective, safe, noninvasive and repeatable. Endoscopic techniques currently used are dilation, multiple plastic stents insertion and fully covered self-expandable metal stents. The main indication for dilation alone is primary sclerosing cholangitis related strictures. In the vast majority of the remaining cases, temporary placement of multiple plastic stents with/without dilation is considered the treatment of choice. Although this approach is effective, it requires multiple endoscopic sessions due to the short duration of stent patency. Fully covered self-expandable metal stents appear as a good alternative to plastic stents, since they have an increased radial diameter, longer stent patency, easier insertion technique and similar efficacy. Recent advances in endoscopic technique and various devices have allowed successful treatment in most cases. The development of novel endoscopic techniques and devices is still ongoing.     

Update on the Indications and Use of Colonic Stents

Self-expandable metal stent (SEMS) placement is a minimally invasive option for achieving acute colonic decompression in obstructed colorectal cancer. Colorectal stenting offers nonoperative, immediate, and effective colon decompression and allows bowel preparation for an elective oncologic resection. Patients who benefit the most are high-risk surgical patients and candidates for laparoscopic resection with complete obstruction, because emergency surgery can be avoided in more than 90% of patients. Colonic stent placement also offers effective palliation of malignant colonic obstruction, although it carries risks of delayed complications. When performed by experienced endoscopists, the technical success rate is high with a low procedural complication rate. Despite concerns of tumor seeding following endoscopic colorectal stent placement, no difference exists in oncologic long-term survival between patients who undergo stent placement followed by elective resection and those undergoing emergency bowel resection. Colorectal stents have also been used in selected patients with benign colonic strictures. Uncovered metal stents should be avoided in these patients, and fully covered stents are associated with high risk of migration. Patients with benign colonic stricture with acute colonic obstruction who are at high risk for emergency surgery can gain temporary relief of obstruction after SEMS placement; the stent can be removed en bloc with the colon specimen at surgery. This article reviews the techniques and indications of SEMS placement for benign and malignant colorectal obstructions.