Fracture of a Self-expandable Metallic Stent Inserted for Malignant Gastric Outlet Obstruction

Duodenal stenting has gradually been established as the first-line treatment for malignant gastric outlet obstruction (GOO). We encountered a case of duodenal stent fracture in a 76-year-old woman with gastric cancer and GOO. She underwent self-expandable metallic stent (SEMS) placement. The SEMS was found to be fractured 4 weeks after its placement. We removed the broken part of the stent and placed a second SEMS. SEMS fracture is a rare and - to the best of our knowledge - unreported complication; hence, clinicians and their patients should be aware of this possibility.     

Hilar Malignant Biliary Obstruction Treated with Four Metallic Stents Involving a New Slim Device

Endoscopic hilar multiple stenting is challenging. A 68-year-old patient had self-expandable metallic stents (SEMSs) inserted for unresectable hilar malignant biliary obstruction. After the SEMSs were inserted into the left hepatic duct and bile duct branch of segment (B) 6, a new SEMS with a wide mesh and slim delivery system was inserted into the right anterior hepatic duct. However, liver abscess and dilated B7 were observed on computed tomography; therefore, an additional new SEMS was quickly and easily inserted into B7. After the placement of these four SEMSs, the liver abscess improved. The new SEMS was effective for hilar multiple biliary drainage.     

A Case of CholangioDuodenal Fistula Formation After Metallic Stenting for Malignant Biliary Stricture

A 68-year-old man presented with melena in June 1993, and was diagnosed as having adenocarcinoma of the rectum with liver metastasis. He underwent anterior resection of the rectum and was given weekly chemotherapy. In October 1993, he developed jaundice due to severe stricture of the middle to lower common bile duct caused by metastatic spread to the lymph nodes around the pancreatic head. A 10mm wide, 51mm long Wallstent^TM (Schneider) was inserted into the lower end of the bile duct through the papilla, resulting in rapid normalization of the serum bilirubin level. Three months later, the Wallstent eroded through the duodenal wall, causing massive fatal hemorrhage. We, therefore, emphasize the necessity of being alert to the potential for such complications in cases involving placement of a self-expanding metallic stent for malignant biliary stricture.     

Tamoxifen-Induced Severe Acute Pancreatitis: A Case Report

Acute pancreatitis is a condition that leads to destruc-tionand necrosis of pancreatic tissue and frequentdevelopment of multiple organ failure. Most cases arerelated to gallstones or heavy alcohol intake. Amongthe numerous other causes are hypertriglyceridemia,hypercalcemia, abdominal trauma, drugs, vasculitis, viralinfection, peritoneal dialysis, cardiopulmonary bypass,and endoscopic retrograde cholangiopancreatography.Approximately 2 to 5% of cases of acute pancreatitisare drug related, including such drugs as azathioprine,mercaptopurine, asparaginase, pentamidine, didanosine,valproic acid, tetracyclines, estrogen, sulfonamides,thiazides, furosemide, pentamidine, dideoxyinosine, andpossibly glucocorticoids.Tamoxifen is a nonsteroidal estrogen antagonist thathas been widely used in adjuvant hormonal therapy ofprimary breast cancer. The side effects of tamoxifenare generally mild, including effects on lipoproteinmetabolism (1-3). Tamoxifen lowers total and low-densitylipoprotein cholesterol and increases triglycerideand high-density lipoprotein cholesterol levels. However,there are some cases of marked, tamoxifen-induced,hypertriglyceridemia. Hypertriglyceridemia may occa-sionallyproduce severe, lethal pancreatitis (4-8). Here,we report a case of tamoxifen-induced severe, acutepancreatitis. The patient was a woman who had hyper-triglyceridemiaand breast cancer. After mastectomy, bothtamoxifen and antihyperlipidemic agents were adminis-tered.But she withdrew the lipid-lowering agent 2 yearslater on her own. Then she developed tamoxifen-inducedsevere hypertriglyceridemia and pancreatitis.     

Combined Use of Uncovered Duodenal and Covered Biliary Metallic Stent for Carcinoma of the Papilla of Vater

We have reported successful implantation of self‐expandable metallic stents for palliative treatment in a case of an 87‐year‐old female patient with carcinoma of the papilla of Vater. She suffered from both duodenal and biliary stenoses, but refused surgical treatment. For the duodenal stenting, a self‐expandable knitted nitinol metallic stent, for esophageal use, was inserted endoscopically. For the biliary stenting, a self‐expandable metallic stent, partially polyurethane‐covered on the proximal part to prevent tumor ingrowth and overgrowth, was inserted via the percutaneous transhepatic biliary drainage route. No major complications occured during these procedures. After the two stents were inserted in an end‐to‐side fashion, she was able to eat a normal diet adequately and suffered from no abdominal symptoms and jaundice during the follow‐up period of 13 months. These stenting procedures might be less invasive and more useful than surgical treatment and provide long patency of biliary stenting and a good quality of life.     

Treating an Intractable Jejunocutaneous Fistula by Endoscopic Metallic Stent Placement: A Case Report of Successful Palliative Endoscopic Treatment in a Case Demonstrating Peritoneal Dissemination with Terminal Stage Gastric Cancer

A 74-year-old woman with recurrent gastric cancer underwent laparotomy for peritoneal dissemination, and the damaged jejunum formed a jejunocutaneous fistula. Because conservative treatment alone could not cure the fistula, we performed an endoscopic placement of a partially covered self-expandable metallic stent (SEMS) to cover the fistula. After the procedure, the contrast medium no longer leaked from the intestinal lumen. One month after stent placement, the cutaneous opening had closed. This case report demonstrates the potential for using partially covered SEMS to treat intractable jejunocutaneous fistula in patients with terminal-stage malignant tumors.     

重症急性胆源性胰腺炎内镜治疗回顾性研究

目的：评价治疗性逆行胰胆管造影术（ERCP）对重症急性胆源性胰腺炎（SABP）的疗效及安全性。方法：回顾分析65例SABP患者内镜治疗情况,比较早期及择期内镜治疗成功率、症状缓解及对预后的影响。结果：65例患者ERCP成功60例（成功率92．3％）。其中急诊ERCP成功率87．7％,择期ERCP成功率100％。33．83％ERCP未见胆管结石。对于无胆道梗阻的SABP患者,比较急诊与择期ERCP组患者的腹痛缓解、体温、白细胞计数、肝功能、淀粉酶等恢复正常时间无显著性差别（P〉0．05）。结论：SABP行治疗性ERCP的诊治创伤小、有效。对于急性期SABP无明确胆道梗阻及感染,早期ERCP增加治疗风险及不成功率;病情稳定后择期ERCP可增加成功率并减少风险,不会加重病情。     

The Diagnostic Value of Procalcitonin in Patients with Severe Acute Pancreatitis: A Meta-Analysis

The role of procalcitonin in diagnosing severe acute pancreatitis has not been clearly assessed. This meta-analysis aims to evaluate the overall diagnostic accuracy of procalcitonin as a biomarker for severe acute pancreatitis. Medline (via PubMed), Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure, and China WanFang Data were searched systematically for prospective studies reporting procalcitonin as a diagnostic marker of severe acute pancreatitis before August 31, 2021. Sensitivity, specificity, and other measures of the accuracy of procalcitonin in the diagnosis of severe acute pancreatitis were pooled by Stata 15.0 software. Heterogeneity was evaluated by I² test, and the quality of included studies was evaluated by using the Quality Assessment of Diagnostic Accuracy Studies-2 system. Further, the sources of heterogeneity were verified using meta-regression and subgroup analysis, and the publication bias was evaluated by the Deeks’ funnel plot. A total of 18 studies meeting the inclusion criteria were included, containing 1764 patients. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and area under the receiver operating characteristic curve of procalcitonin for diagnosing severe acute pancreatitis were as follows: 0.80 (95% CI: 0.73-0.86), 0.84 (95% CI: 0.78-0.88), 4.95 (95% CI: 3.46-7.09), 0.23 (95% CI: 0.16-0.34), 21.26 (95% CI: 11.09-40.74), 0.89 (95% CI: 0.86-0.92). Also, P > .05 suggested no significant publication bias. Current evidence indicates that procalcitonin has good sensitivity and diagnostic accuracy for severe acute pancreatitis. However, the findings should be carefully used as routine evidence in diagnosing patients with severe acute pancreatitis alone because of the limited number of included studies and high heterogeneity.     

COVERED WALLSTENT FOR PALLIATION OF MALIGNANT COMMON BILE DUCT STRICTURE: PROSPECTIVE MULTICENTER EVALUATION

Background: Occlusion due to tumor ingrowth is a major drawback in self‐expandable metallic stents. Covering the stent is a probable solution to prevent tumor ingrowth. A manufactured covered self‐expandable metallic stent, Covered Wallstent, has become commercially available. We evaluated the Covered Wallstent in a prospective uncontrolled multicenter setting. Methods: Between October 2001 and October 2003, 97 patients with common bile duct strictures deemed unfit for surgical resection underwent placement of a single Covered Wallstent, and were followed prospectively until April 2004. Results: Placement of the stent was successful in all the patients attempted. As a procedure‐related complication, acute pancreatitis developed in four patients, in one of whom obstruction of the pancreatic duct orifice with the stent body seemed to be a major cause. The 30‐day mortality was 9.3% (nine patients). Stent occlusion occurred in 22 patients as a late (greater than 30 days) complication, due to either tumor overgrowth (14 patients) or encrustation (eight patients). Distal migration of the stent was demonstrated in two other patients. No stent occlusions due to tumor ingrowth were observed. Patency rates of the stent for 3‐, 6‐, and 12‐month periods were, respectively, 90.7, 82.5, and 45.9%. Conclusions: The present results in a large series suggest that placement of the Covered Wallstent is feasible and effective in the palliation of patients with malignant common bile duct strictures. The Covered Wallstent seems to be reliable in eliminating tumor ingrowth. The role of stent covering in promoting stent function should be examined in a prospective comparative study between covered‐ and uncovered Wallstents.     

急性胰腺炎与胆管结石相关因素探讨及内镜治疗

目的探讨胆管结石与急性胰腺炎的相关因素及内镜治疗。方法回顾性分析了我院196例胆管结石患者的临床资料。根据结石梗阻部位和结石大小分组,比较各组的急性胰腺炎发病率。结果各组胰腺炎发病率有明显差异。结论小结石是胆源性胰腺炎的危险因素,结石梗阻于乳头部,易引起胰腺炎。早期内镜综合治疗效果明显。     

A Case Report of Anomalous Pancreaticobiliary Duct Connection with Choledocholithiasis and Acute Pancreatitis

Abstract: A 25-year-old man was admitted to hospital with epigastric pain. He had had a history of episodic abdominal pain since early childhood. An anomalous pancreaticobiliary duct connection was seen by endoscopic retrograde cholangiopancreatography. In many cases, this type of abnormality is caused by an anomaly in the ventral pancreas. In this case, however, the common bile duct, with calculi, was joined to the pancreatic duct which did not arise from the ventral pancreas but from the dorsal pancreas. The pancreatic duct arising from the ventral pancreas was absent in this case. The patient underwent a prophylactic cholecystectomy, a transduodenal sphincteroplasty, a choledocholithotomy, a partial resection of the common bile duct, and a hepaticojejunostomy, performed by a Roux-en-Y anastomosis. His postoperative recovery was satisfactory. An anomalous pancreatobiliary duct connection allows pancreatic juices and bile to mix. This is considered to be an etiological factor in pancreatitis and choledocholithiasis.     

Current status of endoscopic ultrasound-guided antegrade intervention for biliary diseases in patients with surgically altered anatomy

Endoscopic management of biliary diseases in patients with surgically altered anatomy can be challenging because the altered anatomy makes it difficult to insert an endoscope into the biliary orifice. Even if insertion is feasible, the worse maneuverability of the endoscope and the restriction in available devices and techniques could complicate the procedure. Recently, endoscopic ultrasound-guided antegrade intervention (EUS-AG) has been reported as a useful management method for biliary diseases, especially in patients with surgically altered anatomy. In EUS-AG, the biliary disease is managed in an antegrade fashion through a temporal fistula created under EUS guidance between the intrahepatic biliary duct and upper intestine. In this article, we reviewed the current status of EUS-AG for each biliary diseases, malignant biliary obstruction, bile duct stones, and benign biliary stricture in patients with surgically altered anatomy.     

Endoscopic treatment of extrahepatic bile duct strictures in patients with portal biliopathy carries a high risk of haemobilia: report of 3 cases

Extrahepatic portal venous obstruction can be associated with bile duct abnormalities, the entity being called portal biliopathy. Three cases are reported of extrahepatic bile duct strictures in patients with portal biliopathy who developed haemobilia during endotherapy. Although endoscopic therapy with stent placement can be successful in patients with portal biliopathy and could also lead to permanent stricture resolution, procedure-related haemobilia is not as uncommon as previously held. Shunt surgery could be a better option in fit patients, since it could provide definitive treatment in a young patient with an otherwise normal life expectancy.