Risk factors for cholecystitis after metal stent placement in malignant biliary obstruction

BACKGROUND: Cholecystitis related to metal stent placement is a morbid event. OBJECTIVE: This study evaluated the risk factors of cholecystitis after metal stenting for malignant biliary obstruction. PATIENTS: Between December 1997 and April 2003, 155 patients who were treated with a metal stent for malignant biliary obstruction were retrospectively enrolled. MAIN OUTCOME MEASUREMENTS: The incidence and characteristics of patients with cholecystitis were evaluated and compared with those of patients without cholecystitis. Patient characteristics and tumor or procedure-related data were recorded for the following variables: sex, age, tumor and stent length, stent type (covered vs uncovered), cholangitis before ERCP, degree of gallbladder filling with contrast medium during ERCP, primary disease type (Klatskin vs others), presence of gallbladder stones, and the relationship of the cystic duct orifice to the location of the tumor (across vs others). RESULTS: There were 15 (9.7%) patients diagnosed with cholecystitis after metal stent insertion. The onset of cholecystitis was on average 4.6 days (range 1 to 26) after the procedure. We found that an obstruction across the cystic duct orifice by tumor (P < .01, odds ratio 12.7) and the presence of gallbladder stone (P = .01, odds ratio 6.6) were positively related to the cholecystitis after metal stent insertion. LIMITATIONS: The limitations of the study were the use of multiple types of stents and the retrospective design. CONCLUSIONS: This study demonstrated that an obstruction across the cystic duct by tumor and the presence of gallbladder stone were risk factors for the development of cholecystitis after metal stent placement.     

Pulmonary hemorrhage after intracoronary stent placement

Objectives. The purpose of this study was to determine the incidence and clinical characteristics of pulmonary hemorrhage after intracoronary stent placement.Background. Patients undergoing intracoronary stent placement receive intense anticoagulation to prevent stent thrombosis. Pulmonary hemorrhage during intense anticoagulation is uncommon in other clinical settings but has been diagnosed at our institution after stent placement.Methods. The clinical records of 88 consecutive patients undergoing intracoronary stent placement at a single tertiary referral center were reviewed for evidence of pulmonary hemorrhage. The diagnosis of pulmonary hemorrhage required bronchoscopic demonstration of fresh blood or thrombus in the airways of patients with sudden onset of hemoptysis, dyspnea or hypoxemia and new pulmonary infiltrates on chest radiograph.Results. Pulmonary hemorrhage was identified in 4 (4.5%) of 88 patients undergoing intracoronary stent placement. Patients commonly presented with dyspnea, hemoptysis, hypoxemia, new pulmonary infiltrates on chest radiograph and excessive prolongation of the activated partial thromboplastin time. Mean onset of symptoms was 31.5 h after the procedure. Three of four patients were treated for presumed cardiogenic pulmonary edema until invasive hemodynamic monitoring revealed normal left ventricular filling pressures. Pulmonary hemorrhage resulted in prolonged admissions in the intensive care unit and hospital. One patient died.Conclusions. Pulmonary hemorrhage after coronary stent placement was commonly misdiagnosed and was associated with significant morbidity and mortality in our patients. Although its mechanism is unclear, excessive anticoagulation was a likely contributing factor. Clinical trials comparing varying strategies and intensities of anticoagulation may be indicated.     

全覆膜金属支架治疗良性胆道狭窄的初步研究

目的探讨全覆膜胆道金属支架治疗良性胆道狭窄的安全性及其疗效。方法36例良性胆道狭窄患者行全覆膜胆道金属支架置入术治疗,术后每1～2个月接受1次门诊随访,观察并发症发生及胆道狭窄改变情况。结果36例均一次性成功置入全覆膜胆道金属支架,未出现与操作相关的严重并发症,支架放置3～6个月后全部成功拔除,其中28例（77．8％）良性胆道狭窄消失。结论置入全覆膜胆道金属支架治疗良性胆道狭窄是安全的,近期疗效显著。     

Temporary placement of an expandable polyester silicone-covered stent for treatment of refractory benign esophageal strictures

BACKGROUND: Benign, refractory esophageal strictures are an important therapeutic challenge. Metal stents occasionally have been used, but results have been disappointing. The present study assessed the safety and the efficacy of temporary placement of the new expandable polyester silicone-covered stent for management of problematic esophageal strictures. METHODS: Fifteen patients with benign esophageal strictures were treated by temporary (6 weeks) placement of an expandable polyester silicone-covered stent. All patients had previously been treated, unsuccessfully, by repetitive endoscopic dilation. RESULTS: Stent placement was successful in all patients. There was no procedure-related complication. Dilation with over-the-guidewire polyvinyl dilators was required before stent placement. With the stent in situ, dysphagia completely resolved in all patients. Six weeks after placement, one stent was found to have migrated into the stomach. In the remaining patients, the stent was easily removed with a foreign body forceps. The pretreatment dysphagia score was 3 (range 2-4); the post-treatment score was 1 (range 0-1) (p < 0.0005). Long-term resolution (mean follow-up 22.7 [2.6] months) of the stricture was achieved in 12 patients (80%). The treatment failed in 3 patients, all of whom continue to require periodic dilation. CONCLUSIONS: In patients with benign esophageal strictures refractory to conventional dilation, temporary placement of a removable expandable polyester silicone-covered stent may lead to long-term relief of dysphagia with minimal morbidity.     

Pneumonia in a heart-lung recipient after airway stent placement

Recently, the self-expandable metallic stent (SEMS) has been added to our armamentarium. However, in the case presented here placement of the self-expandable metallic stent had catastrophic consequences 11 months later. We are of the opinion that airway stent placement may result in severe complications including clinical infection, and if it must be deployed, the proper size and positioning of the stent is always of the utmost importance.     

颈段食管梗阻的金属支架治疗

作为介入治疗新技术,内支架治疗因其立竿见影的扩张效果能在非外科的微创性治疗下疏通被阻塞的管腔、及时缓解梗阻症状,因而深受医患双方的欢迎.     

三种食管支架覆膜对支架置入术后再狭窄影响的研究

目的探讨3种覆膜支架置入后引起的食管黏膜局部形态学及病理学变化特点。方法将16只新西兰大白兔分为4组,每组4只。A组置入硅橡胶覆膜镍钛合金支架,B组置入有裙边的硅橡胶覆膜镍钛合金支架（作为对照组）,C组置入有裙边的聚四氟乙烯覆膜镍钛合金支架,D组置入有裙边的聚氨酯覆膜镍钛合金支架。X线辅助下置入支架后,各组分别于术后2、4、6、8周处死1只动物,取出置架部位的食管组织分别行肉眼形态、光学显微镜、电子显微镜观察及免疫组化法检测。结果随着支架置入时间的延长,同一组内食管壁厚度相应增加,支架两端增生严重,局部肉芽组织形成及纤维化,管腔狭窄。以B组作为对照,C组相应部位同一观察时点食管壁的厚度较薄（P〈0．05）。术后2、4、6、8周光镜下观察食管黏膜炎症变化,发现A组重于B组,C组轻于B组,D组与B组相似。A组术后2周少量PCNA阳性表达,术后4周明显表达,术后6周少量表达;B、C、D组术后4、6周明显表达,术后8周少量表达。结论再狭窄主要表现为肉芽组织形成和纤维化,发生于支架两端,下端炎性反应重于上端。不同覆膜食管支架置入后引起的食管黏膜炎症变化有所不同,其中聚四氟乙烯组支架引起的黏膜炎症反应最轻,对局部食管壁的损伤出现的最晚。     

Preliminary study of enteroscopy-guided, self-expandable metal stent placement for malignant small bowel obstruction

Background and Aims: Technical limitations of conventional endoscopes and delivery systems frequently hamper palliative endoscopic placement of self‐expandable metal stents for malignant small bowel obstruction. This study examined feasibility of the double balloon enteroscope‐guided withdrawal‐reinsertion method as a rescue procedure in patients with failed palliative stent placement for malignant small bowel obstruction. Methods: We enrolled 19 consecutive patients with small bowel obstruction due to metastatic gastric (n = 15) or colorectal cancer (n = 2), or primary small bowel carcinoma (n = 2), in whom previous attempts to place self‐expandable metal stents using conventional endoscopy had failed. Ten patients had undergone previous gastric surgery. After passing a guide‐wire using an enteroscope with or without the double‐balloon method, the enteroscope was withdrawn. A conventional endoscope was re‐inserted along the guide‐wire, and through‐the‐scope self‐expandable metal stent placement was performed. Results: Obstruction sites were efferent jejunal loop, proximal jejunum, and third duodenal portion. Technical success was achieved with 94.7% (18/19) of stents, and clinical success occurred with 84.2% (16/19) of patients. The gastric outlet obstruction score (pre‐procedure: 0.68 ± 0.58) increased by one week (2.05 ± 0.52, P < 0.001). Stent migration and restenosis occurred in two (10.5%) and four (21.1%) of 19 stents, respectively. Median stent patency duration was 67 days and median survival was 93 days; these did not differ significantly by palliative chemotherapy (P = 0.76 and 0.67, respectively). Conclusions: The double‐balloon enteroscopy‐guided method followed by conventional endoscopic self‐expandable metal stent delivery was effective for rescue palliation of malignant small bowel obstruction.     

内镜下大肠支架置入术在老年结直肠癌并急性肠梗阻患者中的应用

目的 探讨内镜下大肠支架置入在老年人结直肠癌并急性肠梗阻的临床应用价值.方法 65岁以上结直肠癌并急性肠梗阻患者82例,分为大肠支架组41例,行Niti-S肠道支架置入;以及急诊手术组41例,根据术中探查结果分别行肿瘤切除及结肠造瘘.比较两组的平均住院日,平均住院费用,中位生存时间,1年生存率,围手术期病死率,手术并发症等情况.结果 大肠支架组平均住院日(17.9±6.7)d,平均住院费用40 047元,中位生存时间(9.4±4.4)个月,1年生存率43.9%.急诊手术组平均住院日(24.4±4.6)d,平均住院费用61 867元,中位生存时间(8.8±4.8)个月,1年生存率36.6%.结论 大肠内支架对于结直肠癌合并肠梗阻的老年患者是一种安全、经济、有效的治疗方式.

Abstract：

Objective To evaluate the clinica1 value of endoscopic placement of colorectal metal stents for malignant colonic obstruction in aged patients. Methods The 82 cases who were older than 65 years with malignant colonic obstruction were randomly divided into colorectal metal stenting group who were treated with endoscopic Niti-S colorectal metal stenting and emergency surgery group who were treated with tumor resection or colostomy. The average length of stay, average hospitalization charge, median survival time, one-year survival rate, perioperative mortality, and the complications such as anastomotic leakage, incision infection were analyzed. Results In colorectal metal stenting group, in 39 of 41 patients, metal stents were successfully inserted, without complications of hemorrhage, perforation and so on. And the symptoms of obstruction were effectively relieved within 2 days. The 17 cases underwent subsequent elective radical resection of colorectal carcinoma after 1 week, without complications of anastomotic leakage. The 22 cases were treated with colorectal metal stenting for palliative treatment. There were 4 cases of stent migration and 5 cases of stent obstruction again. The average length of inhospital stay was (17.9±6.7) days, the average hospitalization charge was 40 047 yuan, the median survival time was (9.4±4.4) months, and one-year survival rate was 43.9%. In emergency surgery group, 13 cases underwent tumor resection and 28 cases received colostomy. The 14 cases presented with multiple organ dysfunction, 8 cases died preoperatively, 4 cases presented with anastigmatic leakage. The average length of stay was (24.4±4.6) day, the average hospitalization charge was 61 867 yuan, the median survival time was (8.8±4.8) months, and one-year survival rate was 36.6%. Conclusions Endoscopic colorectal metal stenting is a safe, economic and effective treatment for malignant colonic obstruction in aged patients, especially reduces the risk of surgical complications, improves the aged patient's quality of life.     

Clinical outcomes of secondary stent-in-stent self-expanding metal stent placement for primary stent malfunction in malignant gastric outlet obstruction

Background

Although a substantial number of patients require secondary stents insertion due to primary stent malfunction in malignant gastric outlet obstruction, data on the outcomes of secondary self-expanding metal stents are sparse.

Aim

To investigate clinical outcomes and factors related with secondary stent malfunction in patients with malignant gastric outlet obstruction given secondary stent-in-stent self-expanding metal stent insertion.

Methods

For this retrospective study, a total 77 patients who underwent secondary stent-in-stent self-expanding metal stent placement for primary stent malfunction in malignant gastric outlet obstruction were enrolled. We compared the effectiveness and complications of secondary covered and uncovered stents and explored the predictive factors for stent malfunction.

Results

Stent-in-stent self-expanding metal stent placements were technically successful in all patients. Both groups also had comparable clinical success rates (covered stent, 87.2% and uncovered stent, 90.0%, P = 1.000). Stent malfunction rates (31.9% and 36.7% respectively, P = 0.805) and median patency time of stent (165 [95% confidence interval: 112–218] and 165 [95% confidence interval: 126–204] days, respectively, P = 0.358) were similar between secondary covered and uncovered stents. Longer patients’ survival time (≥100 days) was associated with increased risk of stent malfunction (odds ratio: 4.598; 95% confidence interval: 1.473–14.355; P = 0.009).

Conclusions

Secondary stent-in-stent self-expanding metal stent placement is feasible and effective treatment for primary stent malfunctions in malignant gastric outlet obstruction. Covered and uncovered stent are equally acceptable in terms of stent-related complications and stent patency, regardless of primary stent type.     

Comparison between uncovered and covered self-expandable metal stent placement in malignant duodenal obstruction

AIM:To compare the clinical outcomes of uncovered and covered self-expandable metal stent placements in patients with malignant duodenal obstruction.METHODS:A total of 67 patients were retrospectivelyenrolled from January 2003 to June 2013.All patients had symptomatic obstruction characterized by nausea,vomiting,reduced oral intake,and weight loss.The exclusion criteria included asymptomatic duodenal obstruction,perforation or peritonitis,concomitant small bowel obstruction,or duodenal obstruction caused by benign strictures.The technical and clinical success rate,complication rate,and stent patency were compared according to the placement of uncovered(n = 38) or covered(n = 29) stents.RESULTS:The technical and clinical success rates did not differ between the uncovered and covered stent groups(100% vs 96.6% and 89.5% vs 82.8%).There were no differences in the overall complication rates between the uncovered and covered stent groups(31.6% vs 41.4%).However,stent migration occurred more frequently with covered than uncovered stents [20.7%(6/29) vs 0%(0/38),P < 0.05].Moreover,the overall cumulative median duration of stent patency was longer in uncovered than in covered stents [251 d(95%CI:149.8 d-352.2 d) vs 139 d(95%CI:45.5 d-232.5 d),P < 0.05 by log-rank test] The overall cumulative median survival period was not different between the uncovered stent(70 d) and covered stent groups(60 d).CONCLUSION:Uncovered stents may be preferable in malignant duodenal obstruction because of their greater resistance to stent migration and longer stent patency than covered stents.