Partially versus fully covered self-expanding metal stents for benign and malignant esophageal conditions: a single center experience

Background

Fully covered self-expanding metal stents (FCSEMS), unlike partially covered SEMS (PCSEMS), have been used to treat benign as well as malignant conditions. We aimed to evaluate the outcome of PCSEMS and FCSEMS in patients with both benign and malignant esophageal diseases.

Methods

Data were reviewed of all patients who underwent SEMS placement for malignant or benign conditions between January 1995 and January 2012. Patients with cancer were followed for at least 3 months, until death or surgery. Patients with benign conditions had stents removed between 4 and 12 weeks. Patient demographics, location and type of lesion, stent placement and removal, clinical success, and adverse events were analyzed.

Results

A total of 252 patients (mean ± standard deviation age 68.5 ± 14 years; 171 male) received 321 SEMS (209 PCSEMS, 112 FCSEMS) for malignant (78 %) and benign (22 %) conditions. Stent placement and removal was successful in 97.6 and 95.6 % procedures. Successful relief of malignant dysphagia was noted in 140 of 167 patients (83.8 %) and control of benign fistulas, leaks, and perforations was noted in 21 of 25 patients (84 %), but only 8 of 15 patients (53 %) with recalcitrant benign strictures had effective treatment. Fifty-six patients (22.2 %) experienced at least one stent-related adverse events. Migration was frequent, occurring in 61 of 321 stent placements (19 %), and more frequently with FCSEMS than PCSEMS (37.5 vs. 9.1 %, p < 0.001). FCSEMS, benign conditions, and distal location were the variables independently associated with migration (p < 0.001, p = 0.022, and p = 0.008). Patients with PCSEMS were more likely to have tissue in- or overgrowth than FCSEMS (53.4 vs. 29.1 %, p = 0.004).

Conclusions

Both PCSEMS and FCSEMS can be used in benign and malignant conditions; they are both effective for relieving malignant dysphagia and for closing leaks and perforations, but they seem less effective for relieving benign recalcitrant strictures. Stent migration is more common with FCSEMS, which may limit its use for the palliation of malignant dysphagia.     

Risk of pancreatitis following endoscopically placed large-bore plastic biliary stents with and without biliary sphincterotomy for management of postoperative bile leaks

BACKGROUND: Endoscopic transpapillary biliary stent placement is effective for closure of postoperative bile leaks. Large-bore stents (10 French) may transiently obstruct the adjacent pancreatic duct orifice causing acute pancreatitis. Endoscopic biliary sphincterotomy may reduce this risk, but it introduces separate risks of bleeding and perforation. The objective of this study was to compare complications after large-bore biliary stent placement (10 Fr) with and without sphincterotomy in patients with bile leaks. METHODS: The institutional endoscopy database was queried to identify patients who had undergone endoscopic retrograde cholangiopancreatogrpahy (ERCP) for bile leak between March 1996 and August 2006. Procedural reports were reviewed for evidence of biliary sphincterotomy, cholangiographic and pancreatographic findings, transpapillary stent placement, and procedural complications. Patients with prior biliary sphincterotomy, choledochoenteric anastomosis, placement of multiple biliary stents and expandable metal biliary stents, biliary stents smaller than 10 Fr, and patients in whom a stent was not placed were excluded. The chi-square test was used for categorical variables. Probability 相似文献   

Treating sleeve gastrectomy leak with endoscopic stenting: the kuwaiti experience and review of recent literature

Background

Obesity today is a leading cause of global morbidity and mortality, and bariatric surgeries such as laparoscopic sleeve gastrectomy (LSG) are increasingly playing a key role in its management. Such operations, however, carry many difficult and sometimes fatal complications, including leaks. This study aims at evaluating the effectiveness of endoscopic stenting in treating gastric leaks post-LSG.

Methods

A retrospective study was conducted to the patients who were admitted with post-LSG gastric leak at Al-Amiri Hospital Kuwait from October 2008 to December 2012 and were subsequently treated with stenting. The patients were stented endoscopically with self-expandable metal stent (SEMS), and a self-expandable plastic stent (SEPS) was used to facilitate stent removal.

Results

A total of 17 patients with post-LSG leaks underwent endoscopic stenting. The median age was 34 years (range 19–56), 53 % of the patients were male, and mean body mass index (BMI) was 43 kg/m ² . The median duration of SEMS placement per patient was 42 days (range 28–84). The SEPS-assisted retrieval process took a median duration of 11 days (range 14–35). Successful treatment of gastric leak was evident in 13 (76 %) patients, as evident by gastrografin swallow 1 week after stent removal. In addition, a shorter duration between the LSG and the time of stent placement was associated with a higher success rate of leak seal.

Conclusions

The use of SEMS appears to be a safe and effective method in the treatment of post-LSG leaks, with a success rate of 76 %. The time frame of intervention after surgery is critical, as earlier stent placement is associated with favorable outcomes. Finally, SEPS is often required to facilitate SEMS removal, and further modification of stents and its delivery system may improve results.     

Role of endoscopic stents and selective minimal access drainage in oesophageal leaks: feasibility and outcome

Background

Leaks following oesophageal surgery are considered to be amongst the most dreaded complications and contributory to postoperative mortality. Controversies still exist regarding the best option for the management of oesophageal leaks due to lack of standardized treatment protocols. This study was designed to analyse the feasibility outcome and complications associated with placement of removable, fully covered, self-expanding metallic stents for oesophageal leaks with concomitant minimally invasive drainage when appropriate.

Methods

The study group included 32 patients from a prospectively maintained database of oesophageal leaks, with the majority being anastomotic leaks after minimally invasive oesophagectomy (n = 28), followed by laparoscopic cardiomyotomy (n = 3) and extended total gastrectomy (n = 1). The procedures took place between March 2007 and April 2013.

Results

Most patients had an intrathoracic leak (n = 22), with a mean time to detection of the leak following surgery of 7.50 days (SD = 2.23). Subsequent to endoscopic stenting, enteral feeding via a nasojejunal tube was started on the second day and oral feeding was delayed until the 14th day (n = 31). Six patients underwent thoracoscopic (n = 5) or laparoscopic drainage (n = 1) along with stenting for significant mediastinal and intra-abdominal contamination. The stent migration rate of our study was 8.54 %. The overall success in terms of preventing mortality was 96 %.

Conclusion

Endoscopic stenting should be considered a primary option for managing oesophageal leaks. Delayed oral intake may reduce the incidence of stent migration. Larger stents (bariatric or colorectal stents) serve as a useful option in case of migrated stents. Combined minimally invasive procedures can be safely adapted in appropriate clinical circumstances and may contribute to better outcomes.     

Endoscopic stenting for benign upper gastrointestinal strictures and leaks

Background

Self-expandable metal stents (SEMS) and self-expandable plastic stents (SEPS) maybe used for the treatment of benign upper gastrointestinal (GI) leaks and strictures. This study reviewed our experience with stent insertions in patients with benign upper GI conditions.

Methods

Patients who underwent stent placement for benign upper GI strictures and leaks between March 2007 and April 2011 at a tertiary referral academic center were studied using an endoscopic database and electronic patient records. The technical success, complications, and clinical improvement after stent removal were compared according to type of stent. The outcomes measured were clinical response, adverse events, and predictors of stent migration.

Results

Thirty-eight patients (50 % male, mean age = 54 years, range = 12–82) underwent 121 endoscopic procedures. Twenty patients had stents placed for strictures, and 18 had stents placed for leaks. Stent placement was technically successful in all patients. The average duration of stent placement was 54 days (range = 18–118). Clinical improvement immediately after stent placement was seen in 29 of the 38 patients (76.3 %). Immediate post-procedure adverse events occurred in 8 patients. Late adverse events were seen in 18 patients. Evidence of stent migration occurred in 16 patients and was seen in 42 of the 118 successfully placed stents (35.5 %). Migration was more frequent with fully covered SEMS (p = 0.002). After stent removal, 27 patients were evaluable for long-term success (median follow-up time of 283 days, IQR 38–762). Resolution of strictures or leaks was seen in 11 patients (40.7 %). Predictors for long-term success included increasing age and if the stent did not cross the GE junction.

Conclusions

Placement of SEPS and SEMS for benign refractory strictures and fistulas has modest long-term clinical efficacy and is limited by a significant migration rate. Stent migration is common and frequent with fully covered SEMS compared to other types of stents, regardless of indication or location.     

Stent treatment for fistula after obesity surgery: results in 47 consecutive patients

Background

Leaks occurring after weight loss operations constitute a therapeutic challenge. There is no consensus as to what comprises state-of-the-art management of leaks after bariatric surgery. We sought to determine the efficacy and possible adverse effects of endoluminal stenting for leaks after bariatric surgery.

Methods

We report our experience with the stent treatment of consecutive bariatric patients with a leak (retrospective cohort study). Between October 2005 and July 2010, 47 patients presented an acute leak after a bariatric procedure (61 % primary procedures, 39 % revisions). Fifteen patients were initially approached laparoscopically, and 32 were treated by nonoperative techniques. After adequate drainage and resuscitation, all 47 patients were treated by the endoscopic placement of a partially covered metallic stent, and later of a plastic stent inside the metallic prosthesis to facilitate removal. Both stents were then ablated 1 week later. Primary outcome measurement concerned healing of the fistula, as evidenced by radiographic imaging. Secondary outcomes were length of hospital stay and occurrence of peri- and postprocedural complications.

Results

There was no mortality. 41 patients (87.23 %) healed with stent treatment alone; 5 of the 6 persisting leaks healed with laparoscopic intervention (intention-to-treat success rate 96 %). Complication rate was 28.7 %. Length of hospital stay was mean ± standard deviation 22.4 ± 19.38 days for the patients treated by stent alone, and 23.4 ± 18.4 days for the patients requiring additional surgery (P = NS). One patient developed a stricture and required endoscopic dilation, and one is still awaiting surgical treatment.

Conclusions

Leaks after bariatric surgery can be treated safely and effectively by endoscopic stents. In cases of persisting leaks, laparoscopic intervention is successful in a majority of cases. Late strictures seldom occur.     

Fully Covered Self-Expanding Metal Stents Are Effective For Benign Esophagogastric Disruptions and Strictures

Purpose

Self-expanding fully covered metal stents (CSs) are ideal for use in benign esophagogastric disease. We reviewed our experience with CS to evaluate outcomes, to determine a role for CS in a standard treatment for benign esophageal conditions, and to compare our results with recently published studies.

Methods

We performed a retrospective chart review from 2005 to 2012.

Results

A total of 57 CSs were placed in 44 patients. Indications were stricture (11 patients), anastomotic leak (20), perforation (7), and tracheoesophageal fistulae (6). For GI tract disruptions, open repair or diversion was avoided in 31/33 patients (93.9 %) but required an associated drainage procedure in 22/33 (67 %) patients. Resolution does not depend on achieving radiological control with 6/26 (23 %) having evidence of a persistent leak. Benign strictures were dilated at a mean of 3.7 times prior to stenting. Adjunctive intra-mucosal steroid injections were used in 8/11 patients. Stents were removed at a mean of 33 days. At a mean of 283 days of follow-up, 6/11 (54.5 %) had symptom resolution. The most common complication was stent migration occurring in 17.5 % of patients overall.

Conclusion

Covered stents are an effective adjunct in the management of benign upper gastrointestinal tract fistulae, leaks, perforations and benign strictures.     

Covered stents in cervical anastomoses following esophagectomy

Introduction

Anastomotic complications after esophagectomy are relatively frequent. The off-label use of self-expanding covered metal stents has been shown to be an effective initial treatment for leaks, but there is a paucity of literature regarding their use in cervical esophagogastric anastomoses. We reviewed our outcomes with anastomotic stenting after esophagectomy with cervical esophagogastric reconstruction.

Methods

All stents placed across cervical anastomoses following esophagectomy from 2004 to 2014 were retrospectively reviewed. Indications for surgery and stent placement were collected. For patients with serial stents, each stent event was evaluated separately and as part of its series. Success was defined as resolution of indicated anastomotic problem for at least 90 days. Complications were defined as development of stent-related problems.

Results

Twenty-three patients had a total of 63 stents placed (16 % prophylactic, 38 % leak, 46 % stricture). Sixty percent of patients had successful resolution of their initial anastomotic problem; 67 % required more than one stent. Strictures and leaks healed in 27 and 70 % of patients, respectively, at a median of 55.5 days. Stent-related complications occurred in 78 % of patients. Complications (per stent event) included 62 % migration, 11 % clinically significant tissue overgrowth, 8 % minor erosion (ulcers), and 8 % major erosion. Stents placed for stricture were more likely to result in complications, especially migration (76.7 vs. 48.5 %, p = 0.02). Preoperative chemoradiation was a significant risk factor for erosion (22.5 vs. 4.3 %, p = 0.05), but not for overall complications. Patients with major erosions had longer stent duration compared to those without (92 vs. 36 days, p = 0.14).

Discussion

Although stents are effective at controlling post-esophagectomy anastomotic leaks, they are not effective for treating strictures. Stents have high complication rates, but most are minor. Chemoradiation is a risk factor for stent erosion. Caution should be used when stent duration exceeds 2–3 months due to the risk of erosion.

     

Covered self-expandable metal stents are more associated with complications in the management of malignant colorectal obstruction

Background

The use of self-expandable metal stents (SEMS) for the treatment of malignant colorectal obstruction is increasing. However, results of risk factors for its complications are inconsistent. This study aimed to examine the clinical effectiveness of the procedure as well as the complications and risk factors associated with the complications.

Methods

Medical records of patients with malignant colorectal obstruction who underwent endoscopic placement of covered or uncovered SEMS were reviewed retrospectively. The procedure was performed by two endoscopists with experience in pancreatobiliary endoscopy.

Results

A total of 152 patients were included (102 men; mean age, 70 ± 12.5 years). The procedure was performed for palliative management in 83 patients and performed as a bridge to surgery in 69 patients. There were 111 uncovered stents and 41 covered stents. The technical success rate was 100 % and the clinical success rate 94.1 %. Overall complications were observed in 49 patients (32.2 %) during the follow-up period (median, 98 days; interquartile range, 19–302 days). Obstruction (17.1 %), migration (7.9 %), perforation (5.2 %), bleeding (1.3 %), and tenesmus (0.7 %) were the causes of the complications. Stage IV disease, carcinomatosis peritonei, complete obstruction of the colon, palliative intention, and covered stents increased the complications based on the univariate analysis. Multivariate analysis revealed that complete obstruction of the colon and covered stents were significantly independent risk factors for complications. In the palliative group, Kaplan–Meier analysis showed significantly shorter median duration to the onset of complications in the covered stent group than in the uncovered stent group.

Conclusions

Although SEMS in patients with malignant colorectal obstruction is effective both as palliative therapy and as a bridge to surgery, one-third of patients experienced complications. Severity of obstruction and stent type can influence outcomes.     

Removable and repositionable covered metal self-expandable stents for leaks after upper gastrointestinal surgery: experiences in a tertiary referral hospital

Background

Anastomotic leakages are severe complications of upper gastrointestinal surgery with serious morbidity and mortality. Until recently, only abscess drainage was possible. Since 2007, removable and repositionable covered metal self-expandable stents (RReCoMSeS) have been used in our hospital to cover leaks.

Methods

Patients with postsurgical gastrointestinal leaks treated with RReCoMSeS between January 2007 and March 2010 were retrospectively evaluated and described.

Results

Twenty-six patients were treated with RReCoMSeS (totally covered Choo/Hanaro and partially covered Endoflex stents). Included patients had anastomotic leaks after esophagectomy (15) and bariatric surgery (11). Overall successful sealing of the leak occurred in 81 % (including multiple procedures). In total 33 RReCoMSeS were used (mean 1.3 stents and 1.7 procedures per patient). Twenty-one of 33 RReCoMSeS succeeded in sealing the leak (64 %). Migration occurred in 24 % RReCoMSeS, and 9 % disintegrated. One stent (3 %) caused a perforation.

Conclusions

RReCoMSeS are a safe alternative for treating postsurgical leaks in the upper gastrointestinal tract. In 81 % of patients and with 64 % of the inserted stents, leaks were sealed successfully, with few complications. Fewer stents per patient were needed thanks to their repositionability. Stent migration is a major problem.     

Use of a specially designed partially covered self-expandable metal stent (PSEMS) with a 40-mm diameter for the treatment of upper gastrointestinal suture or staple line leaks in 11 cases

Introduction

The use of self-expandable stents to treat postoperative leaks and fistula in the upper gastrointestinal (GI) tract is an established treatment for leaks of the upper GI tract. However, lumen-to-stent size discrepancies (i.e., after sleeve gastrectomy or esophageal resection) may lead to insufficient sealing of the leaks requiring further surgical intervention. This is mainly due to the relatively small diameter (≤30 mm) of commonly used commercial stents. To overcome this problem, we developed a novel partially covered stent with a shaft diameter of 36 mm and a flare diameter of 40 mm.

Methods

From September 2008 to September 2010, 11 consecutive patients with postoperative leaks were treated with the novel large diameter stent (gastrectomy, n = 5; sleeve gastrectomy, n = 2; fundoplication after esophageal perforation, n = 2; Roux-en-Y gastric bypass, n = 1; esophageal resection, n = 1). Treatment with commercially available stents (shaft/flare: 23/28 mm and 24/30 mm) had been unsuccessful in three patients before treatment with the large diameter stent. Due to dislocation, the large diameter stent was anchored in four patients (2× intraoperatively with transmural sutures, 2× endoscopically with transnasally externalized threads).

Results

Treatment was successful in 11 of 11 patients. Stent placement and removal was easy and safe. The median residence time of the stent was 24 (range, 18–41) days. Stent dislocation occurred in four cases (36 %). It was treated by anchoring the stent. Mean follow-up was 25 (range, 14–40) months. No severe complication occurred during or after intervention and no patient was dysphagic.

Conclusions

Using the novel large diameter, partially covered stent to seal leaks in the upper GI tract is safe and effective. The large diameter of the stent does not seem to injure the wall of the upper GI tract. However, stent dislocation sometimes requires anchoring of the stent with sutures or transnasally externalized threads.     

Factors associated with 30-day readmission and long-term efficacy of enteral stent placement for malignancy

Background

Readmissions to the hospital within 30 days of discharge (30-day readmission rate) may impact stent use in palliative treatment of cancer.

Objective

Our objective was to investigate the incidence of readmission and factors predicting readmissions and long-term outcomes in patients with self-expanding metal stents (SEMS) placed for malignant obstruction.

Methods

Retrospective analysis of all patients who underwent placement of SEMS from 2007 to 2012 for malignant esophageal, gastroduodenal, and colonic obstruction. Incidence and variables associated with 30-day readmission and long-term outcomes were determined.

Results

A total of 191 patients underwent stent placement. The 30-day readmission rate was 17.3 % (N = 33). Readmissions were for stent-related complications in 7.3 % (N = 14) and non-stent-related complications in 9.9 % (N = 19). Stent placement was technically successful in 185 of 191 (96.9 %) and clinically successful in 170 of 191 (89.0 %) patients. On long-term follow-up, 32 (16.8 %) patients needed re-intervention. The mean stent patency was 142 days. Readmission within 30 days was independently associated with development of early complications (<7 days) following stent placement (odds ratio [OR] 5.90; 95 % confidence interval [CI] 2.04–17.1), while the stent location did not impact readmission risk. On Cox regression analysis, American Society of Anesthesiologists physical classification (OR 1.36; 95 % CI 1.02–1.87) and stent location in the esophagus (OR 1.82; 95 % CI 1.10–3.02) were independently associated with long-term mortality.

Conclusions

Early complications following stent placement increase the risk of 30-day readmission. SEMS is efficacious long-term for palliation of malignant gastrointestinal obstruction.     

A novel over-the-scope deployment method for enteral stent placement

Background

Over the last two decades, self-expanding enteral stents have gained popularity and shown therapeutic potential for strictures, obstructions, fistulae, and perforations of the gastrointestinal (GI) tract. Currently available stent delivery systems make deployment in many locations in the GI tract difficult due to the inability to traverse curves or impossible due to the size requirements of the deployment systems.

Methods

A 67-year-old male presented to our hospital with severe gallstone pancreatitis, requiring a prolonged intensive care unit course. Two days after discharge to a rehabilitation facility he developed acute abdominal pain and pneumoperitoneum. Operative exploration failed to identify a perforation. Subsequently, a left-upper-quadrant abscess developed that was drained percutaneously, yielding coliform bacteria. The drain produced several hundred milliliters of stool a day. A barium enema demonstrated a perforation in the descending colon from an old colo-colic anastomosis site. We proposed a novel over-the-scope (OTS) stent deployment method. Utilizing a heat-activated polymer sheath, the stent was affixed to the endoscope. A modified speed-banding attachment was created to permit release of the polymer sheath once endoscopic and fluoroscopic confirmation of the correct position was obtained.

Results

Utilizing this method of OTS stent deployment, a fully covered 23 × 155 mm self-expanding metal stent (WallFlex, Boston Scientific, Natick, MA) was placed in the colon. Endoscopic and fluoroscopic evaluation following stent placement confirmed stent coverage of the perforation with no ongoing evidence of leak. The patient was discharged to his home state 2 weeks after stent placement in stable condition.

Conclusion

We have developed a novel method of OTS stent placement that permits deployment of a variety of enteral stents on any available endoscope. This method permits placement of fully covered stents in locations in the GI tract not reachable with currently available delivery systems.     

Gastric Leak After Laparoscopic Sleeve Gastrectomy: Early Covered Self-Expandable Stent Reduces Healing Time

Background

Laparoscopic sleeve gastrectomy has become a very frequent procedure in bariatric surgery due to its efficacy and simplicity compared to gastric bypass. Gastric staple line leak (1 to 7 % of cases) is a severe complication with a long nonstandardized treatment. The aim of this retrospective study was to examine the success and tolerance of covered stents in its management.

Methods

From January 2009 to December 2011, nine patients with gastric staple line leaks after sleeve gastrectomy were treated with covered stents in our department (seven referred from other institutions). The leaks were diagnosed by CT scan and visualized during the endoscopy. Among the studied variables were operative technique, post-operative fistula diagnosis delay, stent treatment delay, and stent tolerance. In our institution, Hanarostent® (length 17 cm, diameter 18 mm; M.I. Tech, Seoul, Korea) was used and inserted under direct endoscopic control.

Results

Stent treatment was successful in seven cases (78 %). Two other cases had total gastrectomy (405 and 185 days after leak diagnosis). Early stent removal (due to migration or poor tolerance) was necessary in three cases. The average stent treatment duration was of 6.4 weeks, and the average healing time was 141 days. The five patients with an early stent treatment (≤3 weeks after leak diagnosis) had an average healing time of 99 days versus 224 for the four others.

Conclusions

Covered self-expandable stent is an effective treatment of gastric leaks after sleeve gastrectomy. Early stent treatment seems to be associated with shorter healing time.     

An Endoscopic Strategy Combining Mega Stents and Over-The-Scope Clips for the Management of Post-Bariatric Surgery Leaks and Fistulas (with video)

Background and Aims

Endoscopic stenting has proved effective in the management of post-surgical leaks but is strongly hampered by the high rate of stent migration. In this study, we evaluate our experience with a new approach involving the use of novel ultra-large expandable stents tailored for bariatric surgery leaks (Mega stents), combined with the use of the innovative over-the-scope clips (OTSC).

Methods

Retrospective analysis of patients with post-bariatric surgery leaks managed at our institution by an approach combining Mega stents and over-the-scope clips.

Results

Twenty-two patients were treated for post-bariatric surgery leaks; 13 (59 %) had a sleeve gastrectomy while nine (41 %) had a RYGB. A total of 30 stents were inserted. Successful endoscopic insertion and removal were achieved in all patients. OTSC clips were applied in 12 patients (55 %); five simultaneously with stents and seven after stent removal. Primary closure (after one endoscopic procedure) was achieved in 13 patients (59 %) and in a total of 18 patients after multiple endoscopic procedures (82 %). An average of 1.4 stents and 2.8 endoscopic procedures were required per patient. Stent migration occurred in four patients (18 %), and all were retrievable endoscopically. Other complications included retrosternal pain and vomiting in 20 patients (91 %) including one necessitating early removal, bleeding in two patients (9 %), and perforation and esophageal stricture in one patient each (5 %). Two mortalities were encountered, and one of them was stent-related (bleeding).

Conclusion

Mega stents are effective in the management of post-bariatric surgery leaks. The combined use of Mega stents and OTSC clips is associated with a low incidence of migration and a low number of stents and procedures required per patient.

     

Forgotten ureteral stents: Risk factors,complications and management

Objectives

To assess complications of neglected stents, risk factors for the occurrence of complications, and management options and outcomes.

Endoscopic Internal Drainage with Enteral Nutrition (EDEN) for Treatment of Leaks Following Sleeve Gastrectomy

Background

Endoscopic treatment of gastric leaks (GL) following sleeve gastrectomy (SG) involves different techniques; however, standard management is not yet established. We report our experience about endoscopic internal drainage of leaks using pigtail stents coupled with enteral nutrition (EDEN) for 4 to 6 weeks until healing is achieved.

Methods

In 21 pts (18 F, 41 years), one or two plastic pigtail stents were delivered across the leak 25.6 days (4–98) post-surgery. In all patients, nasojejunal tube was inserted. Check endoscopy was done at 4 to 6 weeks with either restenting if persistent leak, or removal if no extravasation of contrast in peritoneal cavity, or closure with an Over-the-Scope Clip® (OTSC®) if contrast opacifying the crossing stent without concomitant peritoneal extravasation.

Results

Twenty-one out of 21 (100 %) patients underwent check endoscopy at average of 30.15 days (26–45) from stenting. In 7/21 (33.3 %) patients leak sealed, 2/7 needed OTSC®. Second check endoscopy, 26.7 days (25–42) later, showed sealed leak in 10 out 14; 6/10 had OTSC®. Four required restenting. One patient, 28 days later, needed OTSC®. One healed at 135 days and another 180 days after four and seven changes, respectively. One patient is currently under treatment. In 20/21 (95.2 %), GL have healed with EID treatment of 55.5 days (26–?180); all are asymptomatic on a normal diet at average follow-up of 150.3 days (20–276).

Conclusions

EDEN is a promising therapeutic approach for treating leaks following SG. Multiple endoscopic sessions may be required.     

Does prophylactic stent insertion to the common bile duct during endoscopic retrograde cholangiopancreatography (ERCP) before cholecystectomy have any impact on the rate of biliary complications?

Background

Patients with choledochocystolithiasis generally undergo endoscopic sphincterotomy (ES) followed by elective cholecystectomy. They can experience the development of recurrent biliary events while waiting for their scheduled surgery.

Aim

This study investigated whether stent insertion before cholecystectomy influences the rate of complications.

Methods

The study compared retrospective and prospective groups of patients with choledochocystolithiasis who underwent ES with or without prophylactic common bile duct stent insertion before cholecystectomy. The rate of emergency cholecystectomies and biliary complications during the waiting period before the elective procedure was analyzed.

Results

For the study, 162 patients with choledochocystolithiasis who underwent endoscopic retrograde cholangiopancreatography (ERCP) with ES were divided to two subgroups. Group A included 52 patients with stent insertion (mean age, 58.3 ± 19.4 years), and group B included 110 patients with no stent insertion (mean age, 61.4 ± 17.7 years) (p = 0.32). Males made up 33.3 % of group A and 53.7 % of group B (p = 0.018). The median time to elective cholecystectomy (open or laparoscopic) was 41.5 days for the patients without bile duct stent insertion before cholecystectomy and 53.5 days for the patients who had the stent insertion before cholecystectomy (p = 0.63). Repeat emergency ERCP due to acute cholangitis was 5.6 % in group A and 1.0 % in group B (p = 0.43). Emergency cholecystectomy rates due to acute cholecystitis after ES were 15.4 % in group A and 14.5 % in group B (p = 1.00). No mortality occurred.

Conclusions

According to the study findings, prophylactic stent insertion during ERCP before cholecystectomy has no impact on biliary complications.     

Pancreatic duct stenting for the duration of ERCP only does not prevent pancreatitis after accidental pancreatic duct cannulation: a prospective randomized trial

Background

Pancreatic duct stent placement during endoscopic retrograde cholangiopancreatography (ERCP) has been recommended in patients at risk for post-ERCP pancreatitis. However, the optimal duration of stent placement remains an open question. Our aim was to compare the efficacy of pancreatic stenting for the duration of ERCP only with spontaneous dislodgment/deferred endoscopic removal in preventing post-ERCP pancreatitis after accidental wire-guided pancreatic duct cannulation.

Methods

All patients in whom accidental wire-guided pancreatic duct cannulation had occurred during ERCP underwent immediate 5-Fr unflanged pigtail pancreatic duct stenting before attempting any other endoscopic maneuver. At the end of the ERCP, patients were randomly assigned to immediate stent removal (group A) or to leaving the stent in place (group B). Assessment of post-ERCP pancreatitis was blind.

Results

Post-ERCP pancreatitis occurred in 6/21 (29 %) patients in group A and in 0/19 patients in group B (P = 0.021); the two groups were well matched for their baseline characteristics. Post-ERCP pancreatitis was mild in two patients, moderate in two patients, and severe in two patients. Stents dislodged spontaneously in 14/19 (74 %) patients within 24–96 h; uneventful endoscopic removal was carried out after 96 h in 5 cases. Proximal stent migration did not occur in any case.

Conclusions

Pancreatic duct stent placement for the duration of ERCP only does not prevent post-ERCP pancreatitis. Pancreatic stents should be left in place until spontaneous dislodgment occurs or endoscopic removal is deemed timely. 5-Fr unflanged pigtail stents remain in place for a period sufficient to prevent post-ERCP pancreatitis and do not migrate proximally.     

Management of distal malignant biliary obstruction with the ComVi stent, a new covered metallic stent

Background

The covered metallic stent is effective for managing malignant distal biliary obstructions. The most popular covered metallic stent is the covered Wallstent (CWS). This study estimated the efficacy and safety of a new expanded polytetrafluoroethylene (e-PTFE)-covered nitinol metallic stent, the ComVi stent. This covered metallic stent consists of an e-PTFE membrane sandwiched between two uncovered metallic stents with weak axial (straightening) force. Wire is exposed on both the inner and outer surfaces.

Methods

Between May 2005 and April 2007, ComVi stents were placed consecutively in 47 patients with unresectable malignant distal biliary obstruction. The cases involved 35 pancreatic cancers, 8 metastatic nodes, 2 gallbladder cancers, and 2 bile duct cancers. The patients were compared with 47 patients who received CWS placement between August 2001 and May 2005 matched for age, sex, and causative disease from 133 cases.

Results

No significant differences in stent patency or patient survival were found. Stent occlusion was observed in 13 patients (27.7%) in the ComVi group and 10 patients (21.3%) in the CWS group. The cause of occlusion in both groups was tumor overgrowth (4.25% vs 4.2%), sludge (8.5% vs 6.3%), impaction of food scraps (14.9% vs 2.1%), and bile duct kinking (0% vs 8.4%). Other complications were migration (2.1% vs 17.0%; p = 0.0304) and cholecystitis (2.1% vs 6.3%), and there were significant differences in the incidence of complications except for occlusion (4.2% vs 24.6%; p = 0.0142).

Conclusion

The ComVi stent has a patency similar to that of the CWS and a lower incidence of migration. However, early occlusion by food impaction was increased and should be resolved.