Endoscopic removal technique of migrated pancreatic plastic stents

Endoscopic pancreatic stenting (EPS) is used for various pancreatic conditions. With the increasing use of pancreatic stents, many complications have been observed. Especially, proximal stent migration presents a more serious condition because of the possibility of pancreatic duct (PD) damage. However, the removal of proximally migrated stents is technically challenging because of the small PD diameter, the bended PD course, the presence of PD strictures, and the lack of suitable devices for stent removal. Thus, few cases of surgical intervention have been encountered. In this study, we review the endoscopic treatment of proximally migrated pancreatic plastic stents. We classify migrated stent conditions into four types according to stent and PD conditions. In Type A, the main pancreatic duct (MPD) has no stricture. In Type B, the stent is positioned across the stricture on the MPD. In Type C, the stent is positioned further away from the stricture on the MPD. The tip of the proximal stent is located in the MPD in types A thru C. In Type D, the tip of the proximal stent is located in a branch duct. We introduced the strategy of endoscopic removal technique of each type of migrated plastic stents.     

Endoscopic techniques for retrieval of proximally migrated biliary stents: the Amsterdam experience

BACKGROUND: Endoscopic retrieval of proximally migrated biliary plastic stents may be technically challenging and sometimes unsuccessful. Despite the widespread use of such stents, there are few reports on the technique for retrieval of migrated stents. METHODS: We reviewed the records of patients who were found to have proximally migrated biliary stents during the last 3 years at a tertiary referral center. Our study analyzed the various techniques used for endoscopic retrieval and evaluated the factors influencing the choice of a particular technique. RESULTS: Endoscopic retrieval of a proximally migrated stent was attempted in 41 patients and was successful in 37 (90%). The retrieval techniques included Dormia basket, balloon, balloon and basket, basket and ball tip catheter, forceps, and Soehendra stent retriever. The Dormia basket technique was successful in the majority of cases. CONCLUSION: Proximally migrated biliary stents can be successfully removed endoscopically in most cases. The choice of a retrieval technique is dependent on several factors including biliary ductal dilatation, depth of stent migration, distal stent impaction and biliary stricture distal to the migrated stent. The placement of an additional stent alongside an irretrievable stent is a satisfactory alternative to retrieval.     

Risk factors for proximal migration of biliary tube stents

AIM: To analyze the risk factors for biliary stent migration in patients with benign and malignant strictures. METHODS: Endoscopic stent placement was performed in 396 patients with bile duct stenosis, at our institution, between June 2003 and March 2009. The indications for bile duct stent implantation included common bile duct stone in 190 patients, malignant lesions in 112, chronic pancreatitis in 62, autoimmune pancreatitis in 14, trauma in eight, surgical complications in six, and primary sclerosing cholangitis(PSC) in four. We retrospectively examined the frequency of stent migration, and analyzed the patient factors(disease, whether endoscopic sphincterotomy was performed, location of bile duct stenosis and diameter of the bile duct) and stent characteristics(duration of stent placement, stent type, diameter and length). Moreover, we investigated retrieval methods for migrated stents and their associated success rates. RESULTS: The frequency of tube stent migration inthe total patient population was 3.5%. The cases in which tube stent migration occurred included those with common bile duct stones(3/190; 1.6%), malignant lesions(2/112; 1.8%), chronic pancreatitis(4/62; 6.5%), autoimmune pancreatitis(2/14; 14.3%), trauma(1/8; 12.5%), surgical complications(2/6; 33.3%), and PSC(0/4; 0%). The potential risk factors for migration included bile duct stenosis secondary to benign disease such as chronic pancreatitis and autoimmune pancreatitis(P = 0.030); stenosis of the lower bile duct(P = 0.031); bile duct diameter > 10 mm(P = 0.023); duration of stent placement > 1 mo(P = 0.007); use of straight-type stents(P < 0.001); and 10-Fr sized stents(P < 0.001). Retrieval of the migrated stents was successful in all cases. The grasping technique, using a basket or snare, was effective for pig-tailed or thin and straight stents, whereas the guidewire cannulation technique was effective for thick and straight stents. CONCLUSION: Migration of tube stents within the bile duct is rare but possible, and it is important to determine the risk factors involved in stent migration.     

Endoscopic ultrasound-guided pancreaticogastrostomy for symptomatic pancreatic duct obstruction caused by migrated pancreatic stent

Endoscopic pancreatic stenting has been widely used in various pancreatic conditions. With the increasing use of pancreatic stents, many complications have been recognized. Especially, proximal stent migration presents a serious condition because of subsequent pancreatic duct obstruction, impaired drainage, ductal dilation, and pancreatic pain. Although endoscopic retrieval is the preferred treatment for proximally migrated pancreatic stents, it is not always successful, resulting in conversion to surgery. To date, endoscopic ultrasound-guided pancreatic duct drainage(EUS-PD) has never been reported for treatment of pancreatic duct obstruction caused by proximally migrated pancreatic stent. We herein describe a case of pancreatic duct rupture and obstruction caused by proximally migrated pancreatic stent that was successfully treated by EUS-guided pancreaticogastrostomy while keeping the former stent in situ after failed endoscopic retrograde cholangiopancreatography. We believe that this report adds to the increasing evidence of symptomatic pancreatic duct obstruction being successfully treated by EUS-PD.     

胰腺分裂内镜治疗价值

目的探讨内镜下治疗胰腺分裂的疗效和安全性。方法收集2006年6月至2013年6月在南京大学医学院附属鼓楼医院消化科就诊的8例胰腺分裂患者的临床资料,对术中及术后情况进行回顾性分析。结果8例胰腺分裂患者共行经内镜逆行胰胆管造影术28例次,均置入胰管支架,其中7例同时行副乳头括约肌切开术,6例行内镜下扩张术,1例行胰管取石术。术后出现1例次轻度胰腺炎。随访2～47个月,1例死于胰腺癌,3例已拔出支架,3例定期复查,1例失访。患者术后慢性胰腺炎急性发作频率及腹痛程度均较术前明显降低。结论内镜下治疗胰腺分裂安全有效,可减少胰腺炎发作频率,减轻术后腹痛程度,术后并发症发生率低。     

Endoscopic retrieval of proximally migrated biliary and pancreatic stents: experience of a large referral center

Background: Proximal migration of a biliary or pancreatic stent is an infrequent event but its management can be technically challenging. Methods: Review of all cases of proximally migrated biliary and pancreatic stents over a 10-year period at a referral pancreatic-biliary center. Data abstracted from patient records included indication for stenting, method of presentation, success of attempt, and method used. Successful methods were determined by reviewing procedure reports. Follow-up was attempted in all patients in whom stent retrieval had failed. Results: Thirty-three proximally migrated bile duct stents, and 26 proximally migrated pancreatic duct stents were identified. Most of the patients were without symptoms. Eighty-five percent of common bile duct stents and 80% of pancreatic duct stents were successfully extracted endoscopically. Seventy-one percent (34 of 48) were retrieved with a basket or balloon. Of the stents not retrieved, two patients did not return for repeat ERCP, three patients with malignant common bile duct strictures were managed with placement of a second stent, three patients with pancreatic duct stents have remained without symptoms with no further retrieval attempts, and three patients with proximally migrated pancreatic duct stents required surgery because of pain and failure of multiple endoscopic retrieval attempts. Conclusion: Over 80% of proximally migrated bile duct and pancreatic duct stents may be extracted endoscopically. Few patients will require surgery. (Gastrointest Endosc 1998;47:486-91.)     

Endoscopic pancreaticobiliary drainage with overlength stents to prevent delayed perforation after endoscopic papillectomy: A pilot study

BACKGROUNDEndoscopic papillectomy (EP) is rapidly replacing traditional surgical resection and is a less invasive procedure for the treatment of duodenal papillary tumors in selected patients. With the expansion of indications, concerns regarding EP include not only technical difficulties, but also the risk of complications, especially delayed duodenal perforation. Delayed perforation after EP is a rare but fatal complication. Exposure of the artificial ulcer to bile and pancreatic juice is considered to be one of the causes of delayed perforation after EP. Draining bile and pancreatic juice away from the wound may help to prevent delayed perforation.AIMTo evaluate the feasibility and safety of placing overlength biliary and pancreatic stents after EP.METHODSThis is a single-center, retrospective study. Five patients with exposure or injury of the muscularis propria after EP were included. A 7-Fr overlength biliary stent and a 7-Fr overlength pancreatic stent, modified by an endoscopic nasobiliary drainage tube, were placed in the common bile duct and pancreatic duct, respectively, and the bile and pancreatic juice were drained to the proximal jejunum.RESULTSEP and overlength stents placement were technically feasible in all five patients (63 ± 12 years), with an average operative time of 63.0 ± 5.6 min. Of the five lesions (median size 20 mm, range 15-35 mm), four achieved en bloc excision and curative resection. The final histopathological diagnoses of the endoscopic specimen were one tubular adenoma with high-grade dysplasia (HGD), one tubulovillous adenoma with low-grade dysplasia, one hamartomatous polyp with HGD, one poorly differentiated adenocarcinoma and one atypical juvenile polyposis with tubulovillous adenoma, HGD and field cancerization invading the muscularis mucosae and submucosa. There were no stent-related complications, but one papillectomy-related complication (mild acute pancreatitis) occurred without any episodes of bleeding, perforation, cholangitis or late-onset duct stenosis.CONCLUSIONFor patients with exposure or injury of the muscularis propria after EP, the placement of overlength biliary and pancreatic stents is a feasible and useful technique to prevent delayed perforation.     

Proximal migration of biliary stents: Attempted endoscopic retrieval in forty-one patients

Background: Proximal migration of a biliary stent is an uncommon event, but its management can present a technical challenge to the therapeutic endoscopist.Methods: We reviewed the methods that have been used for retrieval of proximally migrated biliary stents in a referral endoscopy center.Results: Forty-four cases were identified; 38 stents (86%) were extracted successfully. Half of the stents were retrieved after first passing a guide wire through the stent lumen. Various accessories were then used to withdraw the stents, the Soehendra device being the most popular. Nearly one third were retrieved by grasping the stents directly, usually with a wire basket or forceps. The remainder were recovered after using a stone retrieval balloon alongside the stents to provide traction indirectly. Interventional radiology techniques were needed in two cases, and surgery in one.Conclusions: Cannulating the stent lumen with a wire is often the best approach in patients with a biliary stricture or a nondilated duct. An over-the-wire accessory can then be used to secure the stent. In patients with a dilated duct, indirect traction with a balloon or direct grasping of the stent with a wire basket, snare, or forceps is usually successful. Using these techniques, most proximally migrated biliary stents can be retrieved endoscopically. (Gastrointest Endosc 1995;42:513-9.)     

胰管支架近端移位的原因分析及内镜下治疗

目的探讨胰管支架近端移位的原因及内镜下治疗方式方法。方法2007年4月至2015年1月共967例胆胰疾病患者于南昌大学第一附属医院消化内镜中心置入胰管支架,10例出现胰管支架移位。比较胰管线状支架及胰管单猪尾支架移位发生率,并总结不同类型支架的取出方法。结果胰管线状支架移位率较单猪尾支架更高[3.23%(7/217)比0.40%(3/750)]。对于3例移位的单猪尾支架,2例用活检钳直接取出,另外1例未取出,改再置入一单猪尾支架,术后无不适。对于7例移位的胰管线状支架,2例在导丝引导下通过网篮和球囊将支架拖出乳头口,另外5例导丝引导下用球囊将支架拖出乳头口,后用圈套器一次性成功取出。结论胰管线状支架比单猪尾支架更容易移位,移位后的胰管线状支架可在导丝引导下通过球囊和(或)网篮直接取出,移位后的胰管单猪尾支架可通过活检钳直接取出。     

Wire-guided endoscopic snare papillectomy for tumors of the major duodenal papilla

BACKGROUND: Endoscopic excision for adenoma of the major duodenal papilla was introduced as an alternative to surgery, but postprocedure pancreatitis is a serious drawback. This study assessed the feasibility and the safety of endoscopic papillectomy with a guidewire and pancreatic-duct stent insertion to prevent pancreatitis. METHODS: Six patients were enrolled. The snare loop was passed over a guidewire that had been inserted into the pancreatic duct. Immediately after snare resection, a pancreatic stent was placed along the indwelling guidewire. RESULTS: En bloc papillectomy and pancreatic stent insertion were performed successfully in all patients. Pancreatitis did not develop acutely in any patient. Complications included cholangitis (n = 1) and late-onset pancreatitis owing to the pancreatic stent (n = 1). Scant residual adenomatous tissue was present at resection margins in two patients and was treated endoscopically. CONCLUSIONS: Wire-guided endoscopic snare papillectomy in selected patients is a useful technique that maintains pancreatic-duct access for stent placement. This appears to prevent pancreatitis and to improve the outcome for patients undergoing endoscopic resection of papillary tumors.     

Cholangiopancreatography troubleshooting:the usefulness of endoscopic retrieval of migrated biliary and pancreatic stents

BACKGROUND:Stent migration in the hepatopancreatic duct might arise as one of the rare complications associated with biliary or pancreatic stenting.Although there are some procedures to retrieve the migrated stent,including surgical,percutaneous,and endoscopic approaches,endoscopy should be attempted first because it is least invasive.This study set out to evaluate the usefulness of endoscopic retrieval of migrated biliary and pancreatic stents.METHODS:Plastic stents that migrated in the bile duct(35 patien...     

内镜十二指肠乳头切开术治疗十二指肠乳头旁憩室合并胆总管结石

目的 探讨内镜乳头括约肌切开术(EST)对十二指肠乳头旁憩室合并胆总管结石治疗的方法及价值.方法 我院2005年1月至2009年4月282例EST病例,其中38例为十二指肠乳头旁憩室合并胆总管结石患者,回顾性分析十二指肠憩室对这些病例的ERCP成功率、EST及其并发症的影响.结果 该组38例十二指肠乳头旁憩室合并胆总管...     

Open-biopsy-forceps technique for endoscopic removal of distally migrated and impacted biliary metallic stents

BACKGROUND: Endoscopic removal of distally migrated and impacted biliary metallic stents is technically challenging. An open-biopsy-forceps technique for endoscopic removal of these migrated stents is described. METHODS: The technique was used in 4 patients with distally migrated and impacted covered metallic stents. A closed biopsy forceps was advanced through the stent mesh and opened within the stent to form an "anchor." With endoscope withdrawal, the stent was dislodged easily from the duodenum to the stomach. After grasping an end of the stent with a snare, the stent was removed by complete withdrawal of the endoscope. OBSERVATIONS: In all patients, the impacted stent was removed successfully. Mean time for removal was 10.2 minutes. Although ulceration was evident in the duodenal wall where the distal stent end was impacted in all patients, no other complication or adverse event was observed. CONCLUSIONS: The open-biopsy-forceps technique is useful for endoscopic removal of distally migrated and impacted biliary metallic stents.     

内窥镜逆行胰胆管造影术对胰腺分裂症的诊断、治疗价值研究

目的:探讨内窥镜逆行胰胆管造影术(ERCP)对胰腺分裂症(PD)的诊断、治疗方法及其效果的价值。方法:回顾性分析本院2008年6月至2012年9月明确诊断的20例PD患者的临床表现、诊断及治疗方法,比较治疗前后患者的体重变化,用直观模拟标度尺(VAS)评分来评估腹痛症状改善的情况。结果:患者症状以腹痛为主,急性胰腺炎或慢性胰腺炎急性发作的发生率为75%。经ERCP确诊的患者中,磁共振胆胰管成像(MRCP)的检出率为24%。内镜下治疗包括行内镜下十二指肠主和(或)副乳头切开引流(95%)、胰管支架置入(65%)及鼻胰管引流(55%)。治疗后患者体重增加(P<0.05),疼痛VAS评分下降(P<0.05)。结论:PD患者主要症状为腹痛,急性胰腺炎或慢性胰腺炎急性发作的发生率较高,内镜下治疗可有效减少PD患者腹痛的程度并增加患者体重。     

急性胆源性胰腺炎早期内镜治疗价值

目的探讨急性胆源性胰腺炎早期内镜治疗的价值及其安全性。方法选择92例急性胆源性胰腺炎患者早期（72h内）行ERCP及内镜治疗（ERCP组），并与同期保守治疗40例（对照组）进行比较。结果ERCP组全部成功实施十二指肠乳头切开取石，72例胆总管结石者行网篮及气囊取石，所有92例均行鼻胆管引流，重症组10例同时行胰管支架引流。ERCP组平均腹痛消失时间、血清淀粉酶恢复时间、平均住院天数及平均费用均明显低于对照组。ERCP组重症组病死率8．3％，对照组重症组病死率33．3％。结论急性胆源性胰腺炎早期ERCP治疗是安全的，能降低患者的病死率，减少患者住院天数和费用。     

Percutaneous introduction of a snare for removal of migrated biliary stents

This report describes two cases in which proximally migrated Amsterdam-type biliary stents were extracted using transhepatic snare introduction into the bile ducts. In one case, the migrated stent was removed transhepatically via a percutaneous approach, and in the other a combination transhepatic-endoscopic extraction was successful. No complications were encountered. Percutaneous introduction of snare via transhepatic route offers a good alternative to surgery for removal of migrated biliary stents.     

Stent displacement in endoscopic pancreatic pseudocyst drainage and endoscopic management

A pancreatic pseudocyst(PPC)is a collection of pancreatic fluid enclosed by a non-epithelialized,fibrous or granulomatous wall.Endoscopic pancreatic pseudocyst drainage(PPD)has been widely used clinically to treat PPCs.The success and complications of endoscopic PPD are comparable with surgical interventions.Stent displacement is a rare complication after endoscopic PPD.Almost all the complications of endoscopic PPD have been managed surgically,and there is rare report involving the endoscopic treatment of intraperitoneal stent displacement.We report here a case of stent displacementafter endoscopic ultrasound-and fluoroscopy-guided PPD in a 41-year-old female patient with a PPC in the tail of the pancreas.The endoscopic treatment was successfully performed to remove the displaced stent.The clinical course of the patient was unremarkable.The cyst had significantly reduced and disappeared by 12 wk.We found that both endoscopic ultrasound and fluoroscopy should be used during endoscopic PPD to avoid stent displacement.The displaced stent can be successfully treated by endoscopic removal.     

Urgent endoscopic ultrasound-guided choledochoduodenostomy for acute obstructive suppurative cholangitis-induced sepsis

Acute obstructive suppurative cholangitis (AOSC) due to biliary lithiasis is a life-threatening condition that requires urgent biliary decompression. Although endoscopic retrograde cholangiopancreatography (ERCP) with stent placement is the current gold standard for biliary decompression, it can sometimes be difficult because of failed biliary cannulation. In this retrospective case series, we describe three cases of successful biliary drainage with recovery from septic shock after urgent endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) was performed for AOSC due to biliary lithiasis. In all three cases, technical success in inserting the stents was achieved and the patients completely recovered from AOSC with sepsis in a few days after EUS-CDS. There were no procedure-related complications. When initial ERCP fails, EUS-CDS can be an effective life-saving endoscopic biliary decompression procedure that shortens the procedure time and prevents post-ERCP pancreatitis, particularly in patients with AOSC-induced sepsis.     

Endoscopic transluminal pancreatic necrosectomy using a self-expanding metal stent and high-flow water-jet system

Walled-off pancreatic necrosis and a pancreatic abscess are the most severe complications of acute pancreatitis. Surgery in such critically ill patients is often associated with significant morbidity and mortality within the first few weeks after the onset of symptoms. Minimal invasive approaches with high success and low mortality rates are therefore of considerable interest. Endoscopic therapy has the potential to offer safe and effective alternative treatment. We report here on 3 consecutive patients with infected walled-off pancreatic necrosis and 1 patient with a pancreatic abscess who underwent direct endoscopic necrosectomy 19-21 d after the onset of acute pancreatitis. The infected pancreatic necrosis or abscess was punctured transluminally with a cystostome and, after balloon dilatation, a non-covered self-expanding biliary metal stent was placed into the necrotic cavity. Following stent deployment, a nasobiliary pigtail catheter was placed into the cavity to ensure continuous irrigation. After 5-7 d, the metal stent was removed endoscopically and the necrotic cavity was entered with a therapeutic gastroscope. Endoscopic debridement was performed via the simultaneous application of a high-flow water-jet system; using a flush knife, a Dormia basket, and hot biopsy forceps. The transluminal endotherapy was repeated 2-5 times daily during the next 10 d. Supportive care included parenteral antibiotics and jejunal feeding. All patients improved dramatically and with resolution of their septic conditions; 3 patients were completely cured without any further complications or the need for surgery. One patient died from a complication of prolonged ventilation severe bilateral pneumonia, not related to the endoscopic procedure. No procedure related complications were observed. Transluminal endoscopic necrosectomy with temporary application of a self-expanding metal stent and a high-flow water-jet system shows promise for enhancing the potential of this endoscopic approach in patients with walled-off pancreatic ne     

结肠癌并发肠梗阻经内镜支架置入术临床应用及精细化操作

目的探讨结肠癌并发肠梗阻经内镜支架置入术后的临床应用,通过精细化操作,提高支架置入成功率,减少并发症。 方法收集整理滨州医学院附属医院;淄博矿业集团有限责任公司中心医院2016年1月至2017年8月诊治的结肠癌并发肠梗阻患者26例,其中,男14例、女12例,年龄38～67岁,平均年龄(53.6±3.6)岁。均在X线透视下经内镜置入支架,成功解除梗阻后进行后续治疗。 结果25例患者经内镜成功放入支架,梗阻症状均得到有效缓解或消失,未发生支架脱落、肠道穿孔、大量出血等并发症;1例患者因肠道完全梗阻,导丝不能通过而放弃支架置入。19例患者7～10 d后行腹腔镜下结肠癌根治切除术、6例患者因肿瘤不能手术切除而行永久性内置支架姑息性治疗。 结论通过内镜支架置入术的术前精细准备及术中细致化操作,可以有效避免并发症的发生,为进一步外科手术治疗创造条件,提高患者术后生存率及生活质量。