Microbial colonization and ureteral stent-associated storage lower urinary tract symptoms: the forgotten piece of the puzzle?

Purpose

Ureteral stents are frequently associated with side effects. Most patients suffer from storage lower urinary tract symptoms (LUTS). Storage LUTS are commonly attributed to the irritation of the trigone, smooth muscle spasm or a combination of factors. The relationship between microbial ureteral stent colonization (MUSC) and de novo or worsening storage LUTS has not been investigated yet.

Methods

Five hundred ninety-one polyurethane ureteral stents from 275 male and 153 female patients were prospectively evaluated. The removed stents were sonicated to dislodge adherent microorganisms. Urine flow cytometry was performed to detect pyuria. A standardized urinary symptom questionnaire was given to all patients.

Results

Thirty-five per cent of male and 28% of female cases showed de novo or worsened storage LUTS. MUSC was more common in patients with storage LUTS compared to patients without storage LUTS (men: 26 vs. 13%, respectively, P < 0.05; women: 63 vs. 48%, respectively, P = 0.13). Pyuria was significantly more common in patients with storage LUTS compared to patients without storage LUTS (men: 55 vs. 40%, respectively, P < 0.05; women: 70 vs. 45%, respectively, P < 0.05). No significant correlation was observed between the detected genera of microorganisms and storage LUTS.

Conclusions

Our data show a significant association between MUSC- and stent-related de novo experienced or worsened storage LUTS in men. The incidence of MUSC is most common in both female and male patients with storage LUTS and accompanying pyuria. In these patients, a combination of antibiotics and anti-inflammatory drugs may be regarded as treatment option.     

Metallic ureteral stents in malignant ureteral obstruction: short-term results and radiological features predicting stent failure in patients with non-urological malignancies

Purpose

To provide short-term result of the metallic ureteral stent in patients with malignant ureteral obstruction and identify radiological findings predicting stent failure.

Materials and methods

The records of all patients with non-urological malignant diseases who have received metallic ureteral stents from July 2009 to March 2012 for ureteral obstruction were reviewed. Stent failure was detected by clinical symptoms and imaging studies. Survival analysis was used to estimate patency rates and factors predicting stent failure.

Results

A total of 74 patients with 130 attempts of stent insertion were included. A total of 113 (86.9 %) stents were inserted successfully and 103 (91.2 %) achieved primary patency. After excluding cases without sufficient imaging data, 94 stents were included in the survival analysis. The median functional duration of the 94 stents was 6.2 months (range 3–476 days). Obstruction in abdominal ureter (p = 0.0279) and lymphatic metastasis around ureter (p = 0.0398) were risk factors for stent failure. The median functional durations of the stents for abdominal and pelvic obstructions were 4.5 months (range 3–263 days) and 6.5 months (range 4–476 days), respectively. The median durations of the stents with and without lymphatic metastasis were 5.3 months (range 4–398 days) and 7.8 months (range 31–476 days), respectively.

Conclusion

Metallic ureteral stents are effective and safe in relieving ureteral obstructions resulting from non-urological malignancies, and abdominal ureteral obstruction and lymphatic metastasis around ureter were associated with shorter functional duration.     

Evaluation of a novel gel-based ureteral stent with biofilm-resistant characteristics

Purpose

Current ureteral stents, while effective at maintaining a ureteral lumen, provide a substrate for bacterial growth. This propensity for biofilm formation may be a nidus for bacterial growth leading to infection and a reason for early removal of a stent before it is clinically indicated. A newly devised stent, composed of a highly hydrated, partially hydrolyzed polyacrylonitrile polymer, is believed to have bacterial resistant properties. The objective of this study is to evaluate the biofilm growth and bacterial resistant properties of this novel stent.

Materials and methods

Multiple 1 cm sections of the pAguaMedicina? Pediatric Ureteral Stent (pAMS) (Q Urological, Natick, MA) and the conventional polymer stent (SS) (Boston Scientific, Natick, MA) were incubated for 3 days in the 3 different growth media. Afterward, J96 human pathogenic Escherichia coli was added. At 3, 6, 9, 12, and 15 days following bacterial inoculation, the stent segments were washed, sonicated, and analyzed for bacterial growth. Scanning electron microscopy (SEM) imaging was performed to assess biofilm formation.

Results

pAMS demonstrated significant reductions (43–71 %) in bacterial counts when compared to standard stents in all conditions tested. SEM imaging demonstrated biofilm formation on both types of stents in all media, with a relative reduction in apparent cell debris and bacteria on the pAMS.

Conclusions

In this study, the gel-based stent shows a demonstrable reduction in bacterial counts and biofilm formation. The use of the pAMS may reduce the risk of infection associated with stent usage.     

The use of biodegradable (SX-ELLA) oesophageal stents to treat dysphagia due to benign and malignant oesophageal disease

Background

Biodegradable (BD) oesophageal stents have been available commercially only since 2008 and previous published research is limited. Our aim was to review the use of BD stents to treat dysphagia in benign or malignant oesophageal strictures.

Methods

Patients were identified from a prospective interventional radiological database. BD stents were inserted radiologically under fluoroscopic control.

Results

Between July 2008 and February 2011, 25 attempts at placing SX-ELLA biodegradable oesophageal stents were made in 17 males and five females, with a median age of 69 (range = 54–80) years. Two patients required more than one BD stent. Indications were benign strictures (n = 7) and oesophageal cancer (n = 17). One attempt was unsuccessful for a technical success rate of 96% with no immediate complications. Clinical success rate was 76%. Median dysphagia score before stent insertion was 3 (range = 2–4) compared to 2 (range = 0–3) after stent insertion (p = 0.0001).

Conclusion

BD stents provide good dysphagia relief for the life time of the stent. They may help avoid the use of feeding tubes in patients having radical chemoradiotherapy or awaiting oesophagectomy. They do not require removal or interfere with radiotherapy planning via imaging. However, the reintervention rate is high after the stent dissolves.     

Assessment of readability,quality and popularity of online information on ureteral stents

Objective

To evaluate the quality and readability of online information on ureteral stents.

Methods

Google.com was queried using the search terms “ureteric stent”, “ureteral stent”, “double J stent” and, “Kidney stent” derived from Google AdWords. Website popularity was determined using Google Rank and the Alexa tool. Website quality assessment was performed using the following criteria: Journal of the American Medical Association (JAMA) benchmarks, Health on the Net (HON) criteria, and a customized DISCERN questionnaire. The customized DISCERN questionnaire was developed by combining the short validated DISCERN questionnaire with additional stent-specific items including definition, placement, complications, limitations, removal and “when to seek help”. Scores related to stent items were considered as the “stent score” (SS). Readability was evaluated using five readability tests.

Results

Thirty-two websites were included. The mean customized DISCERN score and “stent score” were 27.1 ± 7.1 (maximum possible score = 59) and 14.6 ± 3.8 (maximum possible score = 24), respectively. A minority of websites adequately addressed “stent removal” and “when to seek medical attention”. Only two websites (6.3%) had HON certification (drugs.com, radiologyinfo.org) and only one website (3.3%) met all JAMA criteria (bradyurology.blogspot.com). Readability level was higher than the American Medical Association recommendation of sixth-grade level for more than 75% of the websites. There was no correlation between Google rank, Alexa rank, and the quality scores (P > 0.05).

Discussion

Among the 32 most popular websites on the topic of ureteral stents, online information was highly variable. The readability of many of the websites was far higher than standard recommendations and the online information was questionable in many cases. These findings suggest a need for improved online resources in order to better educate patients about ureteral stents and also should inform physicians that popular websites may have incomplete information.

     

Feasibility of insertion of a microcatheter through a Y-stent in coil embolization of cerebral aneurysms and its detailed geometry by micro-computed tomography

Background

In Y-stent-assisted coil embolization for cerebral aneurysms, open or closed cell stents are used. Different microcatheters for coil insertion are available. We investigated which microcatheter could be navigated into an aneurysm through a Y-stent with different stents.

Methods

Double Neuroform open-cell stents or double Enterprise closed-cell stents were deployed in Y-configuration in a silicon model of a bifurcation aneurysm. Two endovascular neurosurgeons independently tried to navigate an SL-10 microcatheter for 0.010” coils or a PX Slim microcatheter for 0.020” Penumbra coils into the aneurysm through the Y-stent. In addition, we measured lengths of stent pores of the Y-stents with double Enterprise stents deployed in the model by micro-computed tomography.

Results

It was feasible to navigate an SL-10 microcatheter into the aneurysm through the Y-stent with Enterprise or Neuroform stents. Navigation of a PX Slim microcatheter was feasible in the Y-stents only with Neuroform stents. In the Y-stent with double Enterprise stents, the lengths of the second stent pores were significantly smaller than those of the first stent (0.41?±?0.18 mm vs 0.69?±?0.20 mm; P?=?0.008). The SL-10 microcatheter was smaller than approximately 80 % of the stent pores of the first stent and 30 % of those of the second stent. The PX Slim microcatheter was smaller than 20 % of the stent pores of the first stent and 0 % of those of the second stent.

Conclusions

It was feasible to insert an SL-10 microcatheter into the aneurysm through Y-stents with Enterprise or Neuroform stents. Navigation of a PX Slim microcatheter for 0.020” Penumbra coils was feasible in Y-stents with Neuroform stents, but not with double Enterprise stents. The measurements of stent pores by micro-computed tomography supported this feasibility study. These results may be helpful to select appropriate stents and microcatheters in Y-stent-assisted coil embolization, especially in case of retreatments.     

Outcomes of second self-expandable metallic stent insertion for malignant gastric outlet obstruction

Background

Self-expandable metallic stents are used widely to relieve malignant gastric outlet obstruction (GOO). However, restenosis or migration of first stents is a frequent complication. The purpose of this retrospective cohort study was to evaluate the effectiveness of second stents as an approach to manage failure of first stents in patients with malignant GOO.

Methods

A total of 222 patients with gastric cancer received first stents due to inoperable GOO at National Cancer Center in Korea between January 2008 and June 2011. Monthly follow-up interviews were performed, and second stents (stent-in-stent or stent-after-migration) were inserted in 59 patients by June 2012. Technical and clinical successes and long-term complications were evaluated.

Results

The technical and immediate clinical success rates were 98.3 % (58/59) and 91.5 % (54/59), respectively. Patients who received a second stent due to late complications involving the first stent (migration, restenosis, and fracture) showed a higher clinical success rate (95.8 % [46/48]) than patients who received a second stent due to immediate clinical failure of the first stent (72.7 % [8/11], p = 0.04). The immediate clinical success rate of stent-after-migration (100 % [11/11]) was not different from that of stent-in-stent (89.6 % [43/48], p = 1.0). The stent dysfunction rate of stent-after-migration (27.3 % [3/11]) also was similar to that of stent-in-stent (29.2 % [14/48], p = 1.0). The median patencies of stent-in-stent and stent-after-migration were 27.4 and 58.4 weeks, respectively (p = 0.177). There were no significant prognostic factors for patency of second stents.

Conclusions

Insertion of a second stent is effective for treating the first-stent failure in gastric cancer patients with GOO, especially if the immediate outcome of the first stent was successful.     

Evaluation of Ureteral Stent Colonization in Live-Donor Renal Transplant Recipients

Background

Ureteral stent insertion during kidney transplantation is a matter of debate. Stenting has been proven to reduce the risk of surgical complications. In addition, it has been reported to increase risks such as urinary tract infections especially after operation. Ureteral stent colonization (USC) is known to play a role in the pathogenesis of stent related-infections. The aim of this study was (1) to assess the frequency of USC and values of urine cultures in identifying colonizing bacteria; (2) to assess the importance of indwelling time for USC in live-donor renal transplant recipients; and (3) to evaluate the biomarker role of neutrophil-to-lymphocyte ratio (NLR) on USC.

A randomized controlled trial comparing alpha blocker (tamsulosin) and anticholinergic (solifenacin) in treatment of ureteral stent-related symptoms

Purpose

To compare the effectiveness of tamsulosin and solifenacin in relieving ureteral stents related symptoms.

Patients and methods

A randomized controlled trial was conducted between January 2013 and July 2014. Inclusion criteria were patients aged 20–50 years who underwent temporary unilateral ureteral stent for drainage of calcular upper tract obstruction or after ureteroscopic lithotripsy. Patients with history of lower urinary tract symptoms before stent placement, stents that were fixed after open or laparoscopic procedures, and those who developed complications related to the primary procedure were not included. Eligible patients were randomly assigned to 1 of 3 groups using computer-generated random tables. Patients in group 1 received placebo, patients in group 2 received tamsulosin 0.4 mg once daily, and those in group 3 received solifenacin 5 mg once daily. Ureteral Stent Symptom Questionnaire (USSQ) was answered by all patients 1–2 weeks after stent placement. The primary outcome was the comparison of total score of USSQ between all groups.

Results

The study included 131 patients. All baseline characteristics (age, sex, side, indication, length, and duration of stent) were comparable for all groups. Total USSQ score was 61 in solifenacin group, 76 in tamsulosin group, and 83 in control group (P < 0.001). The total USSQ scores and all domains, except sexual index, were significantly better in solifenacin than in tamsulosin group (P < 0.05).

Conclusion

The use of tamsulosin alone or solifenacin alone in patients with ureteral stents can improve the quality of life by decreasing ureteral stent-related symptoms. Solifenacin was better than tamsulosin.

ClinicalTrial.gov Identifier

NCT01880619.

     

Plasmadeponierte Kohlenstoffbeschichtung auf urologischen Verweilkathetern

Background

Any material placed in the urinary tract is susceptible to the formation of encrustations of crystalline bacterial biofilms. These biofilms cause severe complications in some cases. The strategies used so far for reduction of these complications by surface modifications of the implant material failed to show the expected results.

Patients and methods

In this study, we investigated amorphous carbon coatings (a-C:H) for their ability to effectively reduce or to repress the progressive formation of infection-enhancing crystalline biofilms as new functional surface coatings. In nine patients suffering for several years from stenting, a-C:H-coated ureteral stents were tested in treatment attempts. The current replacement intervals amounted to a mean of 77 days; the principle cause for early replacement was massive stent encrustations associated with symptomatic urinary tract infections.

Results

In total, 20 coated ureteral stents were tested spanning indwelling times between 3 and 4 months. No stent-related complications occurred. In all cases extraordinarily facile handling, less pain during replacement, and markedly increased tolerance were observed. Symptomatic urinary tract infections were reduced by more than 50%. The stents remained virtually free of encrustations.

Conclusion

a-C:H coatings are a novel strategy leading to an enhancement of long-term applicability of ureteral stents and catheters and to improved patient comfort.     

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.     

Relationship between stent characteristics and treatment outcomes in endoscopic transmural drainage of uncomplicated pancreatic pseudocysts

Background

Transmural stents are placed at endoscopy to drain pancreatic fluid collections. This study evaluated the relationship between stent placement and treatment outcomes in patients undergoing endoscopic transmural drainage of uncomplicated pancreatic pseudocysts.

Methods

This is a retrospective study of all patients who underwent endoscopic drainage of uncomplicated pancreatic pseudocysts over a 10-year period. After dilating the transmural tracts in the range of 8–15 mm, single or multiple, 7 or 10Fr double-pigtail plastic stents were deployed. The main outcome measure was to evaluate the relationship between stent characteristics and the number of endoscopic interventions required to achieve resolution of the pancreatic pseudocyst (treatment success).

Results

Of 122 patients, 45 (36.9 %) had 10Fr stents of which 30 patients (66.7 %) had more than one stent; the remaining 77 (63.1 %) patients had 7Fr stents of which 56 (72.7 %) had more than one stent. The overall treatment success was 94.3 %. Treatment was successful in 102 patients (83.6 %) with one intervention; 13 patients (10.7 %) required re-intervention for successful drainage and 7 patients (5.7 %) failed endoscopic treatment. There was no significant difference in the number of interventions required for treatment success between patients with 7 or 10Fr stents (one intervention required in 87.7 vs. 90.5 %, respectively; p = 0.766) and between patients with 1 or >1 stent (one intervention required in 88.9 vs. 88.6 %, respectively; p = 0.999). On multiple logistic regression analysis, the stent size (OR 1.54; 95 % CI 0.23–10.4) and number (OR 1.15; 95 % CI 0.25–5.25) were not associated with the number of interventions required for treatment success when adjusted for pseudocyst size, location, drainage modality, the presence or absence of pancreatic duct stent and luminal compression.

Conclusions

There appears to be no relationship between the number of interventions required for treatment success and stent characteristics in patients undergoing endoscopic transmural drainage of uncomplicated pancreatic pseudocysts.     

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.     

Endoscopic realignment in the management of complete transected ureter

Purpose

To present experience and feasibility of endoscopic realignment for treatment of delayed recognized iatrogenic complete transected ureteral injuries.

Patients and methods

Patients suffering from iatrogenic complete transected ureteral injuries were treated by two surgeons. Five women and 3 men with a mean age of 50.8 years (range 22–69) received diagnosis during the immediate postoperative period (2–6 days after surgery). Ureteral continuity was re-established using a technique combining antegrade flexible ureteroscopy and retrograde rigid ureteroscopy. Then, three ipsilateral 5F double J stents were inserted to assure ureteral patency.

Results

All eight realignment procedures were successful, and no major complications occurred. Average injury length was 1.9 cm (range 1.5–3.0). Average hospitalization time was 8 days (range 3–14). Nephrostomy tubes and stents were removed after a mean period of 3.9 weeks (range 2–6) and 6.8 months (range 5.9–7.1), respectively. At a mean follow-up of 21.5 months (range 10–56), 6 patients were stent-free without image evidence of obstruction, a patient developed strictures was treated with balloon dilation and another exchanged double J stents periodically. No patient has developed significant renal impairment.

Conclusion

Endoscopic realignment is a safe and efficient method as an initial procedure to manage iatrogenic complete transected ureteral injuries in properly selected cases.     

Long-term efficacy of modified retrievable stents for treatment of achalasia cardia

Aim

To investigate the efficacy, safety and optimal duration of placement of modified retrievable metal stents for treatment of achalasia cardia.

Methods

Patients were randomly divided into groups A (N = 26, modified stents for 3 days), B (N = 26, modified stents for 2 days), C (N = 24, balloon dilation), and D (N = 25, regular stents for 2 days). Clinical symptom scores were recorded at baseline, 6 months, and during long-term follow-up.

Results

Seventy-seven patients with achalasia underwent stent placement (100 % success rate of implantation and extraction, no perforation). No stent migration or drop-off occurred in groups A and B. In group D, stent drop-off and migration was observed in 2 and 1 patients, respectively. Two patients in group C sustained esophageal perforation. Patients in the modified stent (A and B), balloon dilated (C) and regular stents (D) groups experienced significant improvement in dysphagia at 6 months, with recurrence in 1.92, 8.33 and 28 %, respectively. The clinical symptom score in the modified stent groups was significantly lower than that in the balloon dilated group (P = 0.01). During long-term follow-up, the symptom scores in modified stent groups were significantly lower than that in the balloon dilated (P < 0.01) and regular stent (P < 0.01) groups.

Conclusion

Modified retrievable metal stents required an optimal placement duration of 2 days were safe with no incidence of migration or drop-off and had a lower recurrence of symptoms.

     

In vitro encrustation of a semi-permanent polymer-covered nitinol ureter stent: an artificial urine model

Purpose

To measure and compare the percentage of surface and luminal thickness of encrustation in Allium and conventional double J ureteric stents after exposure for 6 weeks to an accelerated encrustation model.

Material and Methods

An artificial urine solution was prepared and three stents were immersed into each of six containers allocated to each stent type, representing each week of encrustation. Slight agitation was accomplished by placing a magnetic stirrer at the bottom of each container. Images were obtained by examination under a stereomicroscope and analyzed with the aid of specialized image analysis software (Image J).

Results

By week 2, nearly 100 % of the stent surface was covered by a thin layer of encrustation, gradually increasing in thickness through weeks 3–6. On completion of 6 weeks of encrustation, the 10 mm length double J stent specimens did not show visible encrustation, while the 60 mm long Allium stents showed 100 % surface coverage. This was most evident in the mid-section of the stents compared to the ends, suggesting a correlation between stent length and encrustation formation. There was also no blockage of the lumen of either stents between weeks 1–6.

Conclusion

The designed accelerated encrustation model was successful and showed 80 % surface coverage after 6 weeks. In our study, there appears to be a slightly reduced level of surface encrustation to that of earlier reports. A correlation between stent length and geometry was suggested. This model may be used to compare encrustation for a variety of polymeric stent materials.     

Comparision of Ureteral Stent Colonization Between Deceased and Live Donor Renal Transplant Recipients

Background

The use of a ureteral stent can cause a urinary tract infection (UTI), although it reduces urologic complications. UTIs are associated with a higher rate of ureteral stent colonization (USC). The aim of this study was to compare USC in living and deceased donor renal transplant recipients.

Metallic Stent Placement in Patients with Recurrent Malignant Obstruction in the Surgically Altered Stomach

Purpose

The purpose of this study was to assess the technical feasibility and clinical effectiveness of expandable metallic stent placement in 196 patients with recurrent malignant obstruction in their surgically altered stomach.

Methods

The 196 patients were treated using five different types of gastric surgery performed for gastric cancer: total gastrectomy (type 1) in 73 patients; distal gastrectomy with gastroduodenostomy (type 2) in 39 patients; distal gastrectomy with a Roux-en-Y gastrojejunostomy (type 3) in 21 patients; distal gastrectomy with a gastrojejunostomy (type 4) in 49 patients; and palliative gastrojejunostomy for unresectable gastric cancer (type 5) in 14 patients. The technical and clinical success rates, complications, dysphagia score, and influence of chemotherapy were evaluated and the complications compared between the two stent types. The overall survival and stent patency were calculated using the Kaplan–Meier method.

Results

Stent placement was technically successful in 192 of 196 patients (97.9 %), with 184 of the 192 patients (95.8 %) showing symptomatic improvement. The mean dysphagia score improved from 3.24 ± 0.64 to 1.48 ± 0.82 (p < 0.001). The complication rate was 25 %. The incidence of stent migration was significantly higher in fully covered stents and in patients who underwent chemotherapy (p < 0.001 and p = 0.005, respectively). Chemotherapy was significantly associated with an increase of survival (p < 0.001). The median survival and stent patency were 131 and 90 days, respectively.

Conclusion

Placement of expandable metallic stents in patients with recurrent cancer after a surgically altered stomach is technically feasible and clinically effective. Chemotherapy was associated with increased stent migration and prolonged survival.     

Comparison of uncovered and covered stents for the treatment of malignant duodenal obstruction caused by pancreaticobiliary cancer

Background

Few clinical studies to date have compared different types of self-expandable metallic stents (SEMS) and their outcomes in patients with pure duodenal obstruction caused by pancreaticobiliary cancer. The aim of this study was to compare the clinical effectiveness and side effects of uncovered and covered SEMS for the palliation of duodenal obstruction caused by pancreaticobiliary cancer.

Methods

We retrospectively analyzed all patients with pancreaticobiliary cancer who underwent upper endoscopy with SEMS placement for malignant duodenal obstruction at the National Cancer Center of Korea between April 2003 and December 2010. The technical and clinical success rates of the procedure, complications, and durations of stent patency and overall survival were evaluated.

Results

We identified 70 patients with a mean age of 51.2 years (range = 39–81 years); of these, 46 (65.7 %) had pancreatic cancer, 9 (12.9 %) had bile duct cancer, 11 (15.7 %) had gallbladder cancer, and 4 (5.7 %) had cancer of the ampulla of Vater. Twenty-four patients (34.3 %) received covered SEMSs and 46 (65.7 %) received uncovered SEMSs. Technical and clinical success rates were similar for the covered and uncovered stent groups. The complication rate was higher in the covered than in the uncovered group (62.5 vs. 34.8 %, P = 0.025), due primarily to a significantly higher stent migration rate (20.8 vs. 0 %, P = 0.004). Perforation as a late complication occurred in four patients, two in each group (8.3 vs. 4.3 %, P = 0.425). Stent patency tended to be shorter for covered than for uncovered duodenal stents (13.7 ± 8.6 weeks vs. not reached, P = 0.069).

Conclusions

The use of uncovered stents may be a preferred option for duodenal obstruction secondary to pancreaticobiliary malignancies, since they were effective in preventing stent migration and tended to have longer patency than covered stents. Careful attention should be paid to signs and symptoms of perforation during follow-up.     

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.