金属支架治疗胆道恶性梗阻

目的 探讨金属支架治疗胆道恶性梗阻的价值和适应证。方法 回顾性分析15例植入胆道金属支架治疗不能手术切除的胆道恶性梗阻患者的临床转归，其中胰头癌8例，肝门胆管癌5例，胆囊癌2例。结果 15例患者金属支架均植入成功，术后2周内血清胆红素恢复正常8例（53．3％）、明显减退3例（20．0％）、缓慢减退4例（26．7％）。中位生存时间为12个月，一年生存率46．7％，两年生存率13．3％。结论 对不能切除的胆道恶性梗阻患者放置胆道金属支架操作较简单、痛苦少、并发症少，而且减黄效果好，是一种较为理想的姑息性疗法。     

Endoscopic management of occluded metal biliary stents: metal versus 10F plastic stents

AIM:To compare the efficacy of self-expandable metal stents(SEMSs) with 10F plastic stents(PSs) in the endoscopic management of occluded SEMSs.METHODS:We retrospectively reviewed the medical records of 56 patients who underwent SEMS insertion for palliation of unresectable malignant biliary obstruction between 2000 and 2007 and subsequent endoscopic retrograde biliary drainage(ERBD) with SEMS or PS for initial SEMS occlusion between 2000 and 2008.RESULTS:Subsequent ERBD with SEMS was performed in 29 patient...     

Use of fully covered self-expanding metal stents in benign biliary diseases

Biliary fully covered self-expanding metal stents (FCSEMS) are now being used to treat several benign biliary conditions. Advantages include small predeployment and large postexpansion diameters in addition to an easy insertion technique. Lack of imbedding of the metal into the bile duct wall enables removability. In benign biliary strictures that usually require multiple procedures, despite the substantially higher cost of FCSEMS compared with plastic stents, the use of FCSEMS is offset by the reduced number of endoscopic retrograde cholangiopancreatography interventions required to achieve stricture resolution. In the same way, FCSEMS have also been employed to treat complex bile leaks, perforation and bleeding after endoscopic biliary sphincterotomy and as an aid to maintain permanent drainage tracts obtained by means of Endoscopic Ultrasound-guided biliary drainage. Good success rates have been achieved in all these conditions with an acceptable number of complications. FCSEMS were successfully removed in all patients. Comparative studies of FCSEMS and plastic stents are needed to demonstrate effi cacy and cost-effectiveness     

Retrospective comparison of different percutaneous approaches to manage occluded primary uncovered self-expandable metal stents in patients with unresectable malignant hilar biliary obstruction

Abstract

Purpose: To compare different percutaneous approaches to manage occluded primary uncovered self-expandable metal stents (SEMS) in patients with unresectable malignant hilar biliary obstruction (MHBO).

Materials and Methods: A retrospective study was performed in patients with MHBO who underwent percutaneous management of occluded primary uncovered SEMS between January 2014 and January 2018. Patients were assigned into three groups based on the types of secondary stents, which included SEMS, internal-external drainage (IED), and external drainage (ED). Clinical success, requirement for reintervention, survival times, complications, and cost were evaluated.

Results: A total of 58 patients were identified, with 21, 9, and 28 patients received SEMS, IED, and ED treatments, respectively. The overall clinical success rate was 67.2% (39/58), with no significant difference among three groups (p?=?.489). The median time to reintervention was 82, 57, and 61?days for the SEMS, IED, and ED groups, respectively (p?=?.045 for SEMS vs. IED; p?=?.011 for SEMS vs. ED). There was no significant difference in the median survival times among three groups (p?=?.308). Seven patients (12.7%) experienced minor complications including self-limiting haemobilia (n?=?3) and catheter-related pain (n?=?4). Fourteen patients (24.1%) had major complications, including early cholangitis (n?=?8), pancreatitis (n?=?3), stent dislodgement (n?=?2), and bile leakage (n?=?1). There was no statistical difference in the mean cost of the management of occluded primary SEMS between the three groups (p?=?.162).

Conclusion: Uncovered SEMS could provide a longer duration to reintervention compared to the catheter drainages to manage occluded primary SEMS in patients with unresectable MHBO.     

全覆膜金属支架与塑料支架在不可切除的远端胆道 恶性梗阻中的应用对比研究

目的探讨经内镜逆行胆胰管造影术（endoscopic retrograde cholangiopancreatography,ERCP）下胆道全覆膜金属支架及塑料支架置入治疗远端胆道恶性梗阻性黄疸的有效性及安全性。方法回顾性分析并总结2012年11月—2018年12月收治的52例接受ERCP下全覆膜金属支架（WallFlex）置入和40例胆道塑料支架置入治疗不可切除的恶性梗阻性黄疸患者的操作成功率、临床成功率、通畅时间、堵塞率、再干预次数、总费用等临床资料。结果ERCP 操作成功率两组均为100.0%（92/92）,金属支架组和塑料支架组临床成功率分别为94.2%（49/52）和75.0%（30/40）（χ2 =6.89,P<0.01）。两组生存时间比较,差异无统计学意义（6.5个月比7.2个月, χ2=0.25,P>0.05）。金属支架组中位通畅时间较塑料支架组明显延长（182.0 d 比 84.0 d,P<0.01）。两组胰腺炎（χ2 =0.2,P>0.05）及胆管炎发生率(χ2 =0.2,P>0.05）比较差异无统计学意义。金属支架组发生堵塞的概率要明显少于塑料支架组 [7.8%（4/51）比 25.0%（10/40）, χ2 =5.25,P<0.05],在再次干预次数方面,金属支架组要明显少于塑料支架组（0.06 次比 0.38次,t=2.91,P<0.01）。塑料支架组和金属支架组在总费用上比较差异无统计学意义（42 956.1元比 44 851.5元,t=1.84,P=0.07）。结论ERCP下全覆膜金属支架置入对于不可切除的远端胆道恶性梗阻患者是一种安全、有效、经济的治疗方法,在通畅时间及再次干预次数等方面要明显优于塑料支架。     

经内镜放置胆管金属支架联合鼻胆管引流治疗恶性胆管梗阻

目的探讨经内镜放置胆管金属支架联合鼻胆管引流对恶性胆管梗阻的治疗效果。方法 115例失去手术机会的恶性胆管梗阻患者行经内镜逆行胰胆管造影下放置胆管支架,其中48例行胆管塑料支架引流术,30例行胆管金属支架引流术,37例行胆管金属支架联合鼻胆管引流术;分析各组引流效果、成功率、早期并发症和胆管再堵塞发生情况。结果塑料支架组、金属支架组及金属支架联合鼻胆管组的谷丙转氨酶(ALT)、总胆红素(TBIL)、直接胆红素(DBIL)和碱性磷酸酶(AKP)在手术后均有明显降低(P0.05);手术后1周金属支架联合鼻胆管组的TBIL和DBIL明显低于塑料支架组、金属支架组(P0.05),塑料支架组和金属支架组相比,差异无统计学意义(P0.05);术后3个月内金属支架组和金属支架联合鼻胆管组再堵塞的发生率明显低于塑料支架组(P0.05),金属支架组和金属支架联合鼻胆管组相比,差异无统计学意义(P0.05);塑料支架组的手术成功率与金属支架组及金属支架联合鼻胆管组相比,差异无统计学意义(P0.05),塑料支架组的早期并发症发生率明显高于金属支架联合鼻胆管组,差异有统计学意义(P0.05)。结论经内镜逆行胰胆管造影下放置胆管金属支架联合鼻胆管对于恶性胆管梗阻有确切的引流效果。     

Endoscopic retrograde cholangiopancreatography in pancreatic and biliary tract disease in Korean children

AIM:To assess the indications,findings,therapeutic procedures,safety,and complications of endoscopic retrograde cholangiopancreatography(ERCP) performed in Korean children.METHODS:The demographic characteristics,indications for ERCP,findings,therapeutic procedures,and complications of 122 pediatric patients who underwent 245 ERCPs in the Asan Medical Center between June 1994 and March 2008 were investigated.RESULTS:The mean age of the 122 patients was 8.0 ± 4.2 years.Indications were biliary pathology in 78...     

Clinical outcomes and patency of self-expanding metal stents in patients with malignant colorectal obstruction: a prospective single center study

BACKGROUNDS AND AIMS: Self-expanding metal stents (SEMS) have been used as a palliative treatment for malignant colorectal obstruction. However, the reports about primary stent patency rate and associated factors have been limited. This study was performed to evaluate clinical outcomes and factors associated with long-term complications and patency of SEMS in patients with malignant colorectal obstruction. MATERIALS AND METHODS: Patients who underwent palliative endoscopic placement with uncovered SEMS for a malignant colorectal obstruction were prospectively enrolled at Seoul National University Hospital between April 2005 and August 2007. RESULTS: Forty-nine patients underwent 51 SEMS placements. Obstruction sites were rectum in 15 patients (30.6%), descending or sigmoid colon in 25 (51.0%), and transverse colon in nine (18.4%), respectively. The causes of obstruction were colorectal cancer in 36 patients (73.5%), direct invasion of gastric cancer in seven (14.3%) and others in six (12.2%). Technical success was achieved in 100% and clinical success in 86%, and there was one procedure-related perforation. Re-obstruction and migration occurred in 16% and 6%, respectively, during mean follow-up period of 331 days. Median stent patency duration was 204 days, and patency rates at 30, 90, and 180 days were 91.2%, 81.0%, and 53.3%, respectively, which was not associated with patient demographics, site of obstruction, or palliative chemotherapy. CONCLUSION: Endoscopic SEMS placement is a safe and effective palliative treatment for malignant colorectal obstruction, and overall long-term complication and patency were favorable irrespective of the palliative chemotherapy.     

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.     

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.     

内镜逆行胰胆管造影患者术后胆道感染的病原学分析及治疗

目的探究内镜逆行胰胆管造影(ERCP)术后患者胆道感染的原因及病原种类和耐药性,依据感染原因及病原种类为临床治疗提供相关参考。方法对莱芜市人民医院消化内科2009年3月-2013年3月740例行ERCP手术患者进行临床分析,根据梗阻部位分为:肝门组、肝总管组、胆总管组及胆管未见异常组,比较各组间感染的发生率;通过抽取胆道感染者的血样进行病原菌培养,对病原菌的含量进行分析。结果 740例患者有200例发生感染,总感染率为27.03%,肝门梗阻感染者120例,感染率为81.08%,肝总管组感染48例,感染率为40.00%,胆总管组感染22例,感染率为8.87%,胆管未见异常组感染10例,感染率为4.46%,四组之间相比,差异有统计学意义(P0.05);通过对感染者术后血液或者胆汁培养致病菌得到320株,其中革兰氏阴性占70.00%,革兰氏阳性菌占30.00%,占前三位的菌株分别是:大肠埃希菌、尿肠球菌和粪肠球菌;通过药敏试验可知革兰氏阴性菌对亚胺培南100%敏感,革兰氏阳性菌对万古霉素100%敏感,病原菌对其他抗菌药物均有一定的耐药性。结论 ERCP术后感染和梗阻部位有着显著的相关性,因此要依据梗阻部位做好防止感染发生的准备;通过病原菌的培养和耐药性的检测,从而提高ERCP术后胆道感染控制率,为临床治疗提供参考。     

Gastrointestinal and biliary stents

Advances in stent design have led to a substantial increase in the use of stents for a variety of malignant and benign strictures in the gastrointestinal tract and biliary system. Whereas early stents were mostly composed of plastic, the majority of contemporary stents are self‐expanding metal stents that are composed of either nitinol or stainless steel. These stents are able to exert an adequate expansile force and, at the same time, are highly flexible and biocompatible. Covered stents have been introduced to minimize tumor ingrowth through the metal mesh but are associated with higher rates for spontaneous migration. This has led to the development of covered stents with uncovered ends and stents with both covered and uncovered layers. Drug‐eluting and biodegradable stents are also likely to become available in the near future. Although stents appear to be the preferred form of palliation for some patients with advanced cancer, many patients will benefit from a multidisciplinary approach that usually includes surgeons and oncologists.     

A 17 years retrospective study on multiple metal stents for complex malignant hilar biliary strictures: Survival,stents patency and outcomes of re-interventions for occluded metal stents

BackgroundEndoscopic placement of SEMSs for malignant hilar biliary strictures (MHBS) is well-established palliative treatment for inoperable patients. Objectives of this study were evaluation of survival and stents patency after placement of multiple SEMS for palliation of complex MHBS.MethodsRetrospective review of patients with MHBS that underwent ERCP with insertion of multiple SEMSs for palliation. Survival-associated factors and stents patency were analyzed by Cox multivariate analysis.ResultsBetween January 1998 and January 2015, 740 patients with nonoperable MHBS that underwent ERCP were identified and only 18.2% of these received multiple SEMSs. Complications were observed in 7.5% of the patients with no procedure-related mortality. Palliative therapies (chemotherapy, external beam radiotherapy and high dose rate brachytherapy) were done in some patients, and outcomes were evaluated. Overall mean survival of the 134 patients was 323 days. Of these, 59% did not had stents malfunction while 41% patients had episodes of SEMSs malfunction and mean survival after re-interventions was 502.9 days. Survival was not influenced by type of tumor, sex or age.ConclusionsEndoscopic multiple SEMSs placement is safe and effective in patients with complex MHBS. Survival is independent from the type and complexity of MHBS while is prolonged in patients undergoing HDR brachytherapy. Prompt recognition of SEMSs malfunction is fundamental for survival.     

Endoscopic palliation of malignant biliary obstruction

Malignant biliary obstruction often presents with challenges requiring the endoscopist to assess the location of the lesion, the staging of the disease, the eventual resectability and patient preferences in term of biliary decompression. This review will focus on the different modalities available in order to offer the most appropriate palliation, such as conventional endoscopic retrograde cholangiopancreatography, endoscopic ultrasound guided biliary drainage as well as ablative therapies including photodynamic therapy or radiofrequency ablation.     

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.     

A temporary self-expanding metallic stent for malignant colorectal obstruction

AIM:To investigate the clinical safety and efficacy of a temporary self-expanding metallic stent(SEMS) for malignant colorectal obstruction.METHODS:From September 2007 to June 2012,33 patients with malignant colorectal obstruction were treated with a temporary SEMS.The stent had a tubular configuration with a retrieval lasso attached inside the proximal end of the stent to facilitate its removal.The SEMS was removed one week after placement.Clinical examination,abdominal X-ray and a contrast study were prospectively performed and both initial and follow-up data before and at 1 d,1 wk,and 1 mo,3 mo,6 mo and 12 mo after stent placement were obtained.Data collected on the technical and clinical success of the procedures,complications,need for reinsertion and survival were analyzed.RESULTS:Stent placement and removal were technically successful in all patients with no procedurerelated complications.Post-procedural complications included stent migration(n = 2) and anal pain(n = 2).Clinical success was achieved in 31(93.9%) of 33 patients with resolution of bowel obstruction within 3 d of stent removal.Eleven of the 33 patients died 73.81 ± 23.66 d(range 42-121 d) after removal of the stent without colonic re-obstruction.Clinical success was achieved in another 8 patients without symptoms of obstruction during the follow-up period.Reinsertion of the stent was performed in the remaining 12 patients with re-obstruction after 84.33 ± 51.80 d of follow-up.The mean and median periods of relief of obstructive symptoms were 97.25 ± 9.56 d and 105 ± 17.43 d,respectively,using Kaplan-Meier analysis.CONCLUSION:Temporary SEMS is a safe and effective approach in patients with malignant colorectal obstruction due to low complication rates and good medium-term outcomes.     

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.     

Tips and troubleshooting for transpapillary metal stenting for distal malignant biliary obstruction

Endoscopic placement of a self‐expandable metal stent (SEMS) has become a mainstream treatment to relieve non‐resectable distal malignant biliary obstructions—its longer patency and cost‐effectiveness were demonstrated in comparison with plastic biliary stents in several randomized controlled trials. Despite advances in ERCP devices and SEMSs themselves to enable safe and effective biliary drainage via a SEMS, several significant aspects of the endoscopic placement of SEMS must be considered; otherwise, SEMS‐related complications and early SEMS dysfunction may occur. Also, SEMS dysfunction, including occlusion and migration, occurs at a certain frequency in the long term, and appropriate reintervention is necessary to preserve the quality of life of the patient. Here, we present tips for endoscopic transpapillary SEMS placement for distal malignant biliary obstruction and reintervention for SEMS dysfunction.