7F Stent Research Articles

Biliary drainage in hilar and perihilar cholangiocarcinoma: 25-year experience at a tertiary cancer center

This study analyzed the optimal biliary stenting strategy for palliation in cholangiocarcinoma (CCA). This was a retrospective study of patients with CCA who underwent biliary drainage from 1997 to 2023. A per-patient analysis of percutaneous transhepatic biliary drainage (PTBD) rates, the median number of ERCPs, and overall survival (OS) and a per-procedure analysis of clinical success (CS), stent-specific adverse events (AEs), and mean time to repeat ERCP by stent type and laterality (unilateral and bilateral) are presented. A total of 333 patients underwent 1050 ERCPs, 85% with plastic stents (PSs). PTBD was eventually done in 23% of PS patients, 35% of whom had their PS removed before PTBD. ERCPs with the use of self-expandable metal stents (SEMSs)/unilateral SEMSs had higher CS (89%/91%) versus PSs/unilateral plastic stents (uPSs) (85% both) and PSs within SEMSs (PS-SEMSs)/uPS-SEMSs (71%/74%; P= .013/P= .054). Compared with PSs, SEMSs and PS-SEMSs were associated with higher stent-specific AEs (odds ratios [ORs]: SEMSs 4.85 [95% confidence interval (CI), 3.23-7.27], PS-SEMSs 9.99 [95% CI, 5.33-18.71]; P< .001). Straight PSs were associated with more stent-specific AEs compared with double-pigtail stents (OR 6.74 [95% CI, 3.95-11.45]; P< .001). More 7F stents were used in cases with balloon dilation (BD) (109 with BD vs 88 without BD; P< .001). BD had a 79% CS rate versus 87% without BD (P< .001). Cases with pus on ERCP and those with BD had a shorter mean time to repeat ERCP. On regression analyses, higher Bismuth class, PS use, and PS-SEMS use were associated with a shorter mean time to repeat ERCP. Fifty-two percent of patients in the bilateral SEMS arm died from cholangitis (P= .005). The relatively higher CS rate of SEMSs is countered by the higher stent-specific AE rate. PSs can be removed and may better facilitate PTBD. Within PS types, double-pigtail stents may have fewer stent-specific AEs. Cases requiring BD and with endoscopic evidence of pus may benefit from earlier reintervention.

Benign biliary strictures associated with acute biliary pancreatitis.

There are limited data about the benign biliary strictures (BBS) which can develop during the clinical course of acute biliary pancreatitis (ABP) due to compression of the common bile duct (CBD) by edematous and inflamed pancreatic tissue. We aimed to determine the incidence of BBS due to ABP and its clinical course after endoscopic management. The study was retrospectively conducted among patients with ABP who were admitted to a single tertiary reference center during 3years. BBS-ABP was defined as distal narrowing of the CBD with proximal dilatation and delayed drainage of the contrast into the duodenum. Endoscopic treatment was performed by inserting a single 7F or 10F plastic stent which was exchanged every 3months until stricture resolution. Patients were followed for 1year after stricture resolution. Seven hundred and twenty-one patients had ABP during the study period. Among them, 257 (35.6%) patients underwent ERCP and 26 patients (3.6%) had CBD stricture due to ABP. A 7 Fr plastic stent was inserted in 18 patients and 10 Fr in 8 patients. The stricture was completely resolved at 3months in 66.7%, at 6months 23.8% and at 9months (9.5%) of the patients. There was no procedure-related complications other than asymptomatic stent migration in 4 (19%) patients. None of the patients had recurrent biliary stricture during the 1year stent-free follow-up period. BBS-ABP is a frequently seen clinical entity. In most patients, the stricture improves within 3months and temporary endoscopic stenting prevents the patients from the consequences of the obstruction during this period.

Troubleshooting of embedded M-Intraductal lasso in fistula of endoscopic ultrasonography-guided hepaticogastrostomy.

Watch a video of this article.

Magnetic resonance imaging of invitro urine flow in single and tandem stented ureters subject to extrinsic ureteral obstruction.

To quantify the relative volumetric flows in stent and ureter lumina, as a function of stent size and configuration, in both unobstructed and externally obstructed stented ureters. Magnetic resonance imaging was used to measure flow in stented ureters using a phantom kidney model. Volumetric flow in the stent and ureter lumina were determined along the stented ureters, for each of four single stent sizes (4.8F, 6F, 7F, and 8F), and for tandem (6F and 7F) configurations. Measurements were made in the presence of a fully encircling extrinsic ureteral obstruction as well as in benchmark cases with no extrinsic ureteral obstruction. Under no obstruction, the relative contribution of urine flow in single stents is 1-10%, while the relative contributions to flow are ~6 and ~28% for tandem 6F and 7F, respectively. In the presence of an extrinsic ureteral obstruction and single stents, all urine passes within the stent lumen near the extrinsic ureteral obstruction. For tandem 6F and 7F stents under extrinsic ureteral obstruction, relative volumetric flows in the two stent lumina are ~73% and ~81%, respectively, with the remainder passing through the ureter lumen. Magnetic resonance imaging demonstrates that with no extrinsic ureteral obstruction, minimal urine flow occurs within a stent. Stent lumen flow is significant in the presence of extrinsic ureteral obstruction, in the vicinity of the extrinsic ureteral obstruction. For tandem stents subjected to extrinsic ureteral obstruction, urine flow also occurs in the ureter lumen between the stents, which can reduce the likelihood of kidney failure even in the case of both stent lumina being occluded.

The Impact of Ureteral Deformation and External Ureteral Pressure on Stent Failure in Extrinsic Ureteral Obstruction: An In Vitro Experimental Study.

Background and Purpose: Extrinsic ureteral obstruction is caused frequently by pelvic malignancies or metastatic lymphadenopathy, necessitating renal drainage with ureteral stents to prevent renal failure and kidney damage. Understanding the nature of stent behavior under deformation and realistic external pressures may assist in evaluation of stent performance. Few published studies have investigated the flow and mechanical properties of stents within ureters, and none has considered the effects of deformation and compression on flow in realistic, in vitro, ureter-stent systems. The purpose of this work was to determine whether or not stent failure is due only to stent compression and deformation in the presence of extrinsic obstruction. Methods: We developed an in vitro ureter-stent experimental setup, using latex tubing to simulate a flexible ureter connecting a renal unit and a bladder side. We examined flow behavior in three stents (4.8F, 6F, 7F). The ureter-stent configuration was varied, simulating four levels of deformation (0°, 20°, 40°, 60°) and then simulating different external compressive forces on a stented ureter with 40° deformation. A constant, realistic fluid flow was applied through the ureter-stent configurations, and pressure fluctuations in the renal unit were monitored. Results: Deformation alone on four different levels (0°, 20°, 40°, 60°) has essentially no influence on fluid flow and renal pressure variation. Under increasing external compressive forces of 500, 1000, 2000, and up to 5000 g at 40° deformation, no effect on fluid flow and pressure within the renal unit was noted for the 6F and 7F stents. The only exception was for the 4.8F stent, which demonstrated complete failure at compressive forces near 4000 g. Conclusions: Neither realistic extrinsic ureteral compression forces nor ureteral deformation explain the high frequency of stent failure in extrinsic ureteral obstruction. Other factors such as urine composition may be a major contributor to stent failure.

Feasibility and safety of a novel dedicated device for one-step EUS-guided biliary drainage: A randomized trial.

EUS-guided biliary drainage (EUS-BD) has been proposed as an alternative for patients after failed ERCP. To date, the evaluation of dedicated device for one-step EUS-BD has been limited. To determine feasibility and safety of a newly designed 7F stent introducer with tapered metal tip as a push-type dilator for one-step metal stent placement without additional fistula dilation in EUS-BD. Thirty-two patients with malignant biliary obstruction and failed ERCP were randomly assigned to a dedicated stent introducer with a modified hybrid metal stent (DH group, n = 16) or a conventional 8.5F biliary metal stent introducer with a fully covered metal stent (FC group, n = 16). The technical success, procedural times, clinical success rate, and adverse event rates were evaluated. One-step technical success without additional fistula dilation in the DH was 88% (14/16). Multi-step process in a stent placement was performed in all patients of the FC group. The procedural time in the DH was significantly shorter than the FC (10 vs. 15 min, P = 0.007). No difference in overall technical or clinical success was seen between the groups. The rate of an early adverse event was common in the FC compared with the DH (31.3% [5/16] in the FC vs. 6.3% [1/16] in the DH, P = 0.172), although not statistically significant. A dedicated device for one-step EUS-BD may be technically feasible, safe, and shorten the procedural times with less chance of an additional fistula dilation process, resulting in a potential reduction of the early adverse events.

EUS-guided wirsung-gastrostomy: Outcomes and long-term management

Introduction: Technical success for endoscopic wirsung-gastrostomy (EWG) is about 40% with a complication rate >20%. Long-term results are scarce. Case: A 46 year old patient with alcoholic liver and pancreatic chronic disease with active consumption referred recurrent pancreatic like type pain requiring intensive analgesic therapy. CT scan showed pancreatic duct dilation proximal to the head of the pancreas with distal pancreatic duct stenosis and severe perigastric collateral vessels related to portal hypertension. The patient was considered as high surgical risk so in October 2011 pancreatic stent placement was attempted but failed because of impossibility of pancreatic duct cannulation. EUS-guided transgastric pancreatic duct access was performed. Wirsungraphy was accomplished through the transgastric EUS guided needle showing a severe pancreatic duct stenosis in the pancreatic isthmus hindering guidewirenavigation and the EWGwas completed by insertion of a 5F pancreatic stent connecting the pancreatic duct and the gastric lumen. The patient had a favourable outcome and could stop taking analgesics. In may 2012 a second transgastric 7F stent placement was scheduled uneventfully to ensure pancreatic drainage. The patient remained asymptomatic thereafter despite keeping toxic habits, until august 2013 when he was admitted for a septic clinical picture with abdominal pain. A CT scan showed two abdominal collections with transgastric pancreatic stents correctly placed. The patient was diagnosed of acute relapse over chronic pancreatitis and percutaneous drainage of both collections was performed. In order to rule out origin of those collections from the EWG, the transgastric fistula was cannulated showing no leakage and improvement of the pancreatic head stenosis. Three plastic pancreatic stents were placed through the gastric wall into the pancreatic duct. The patient remains asymptomatic 40 months after initial EWG. Conclusion: In our experience, the EWG offers good clinical long-term outcomes in patients with high surgical risk.

Intervencional endoscopy for the treatment of walled off necrosis: A single center experience

Introduction: Technical success for endoscopic wirsung-gastrostomy (EWG) is about 40% with a complication rate >20%. Long-term results are scarce. Case: A 46 year old patient with alcoholic liver and pancreatic chronic disease with active consumption referred recurrent pancreatic like type pain requiring intensive analgesic therapy. CT scan showed pancreatic duct dilation proximal to the head of the pancreas with distal pancreatic duct stenosis and severe perigastric collateral vessels related to portal hypertension. The patient was considered as high surgical risk so in October 2011 pancreatic stent placement was attempted but failed because of impossibility of pancreatic duct cannulation. EUS-guided transgastric pancreatic duct access was performed. Wirsungraphy was accomplished through the transgastric EUS guided needle showing a severe pancreatic duct stenosis in the pancreatic isthmus hindering guidewirenavigation and the EWGwas completed by insertion of a 5F pancreatic stent connecting the pancreatic duct and the gastric lumen. The patient had a favourable outcome and could stop taking analgesics. In may 2012 a second transgastric 7F stent placement was scheduled uneventfully to ensure pancreatic drainage. The patient remained asymptomatic thereafter despite keeping toxic habits, until august 2013 when he was admitted for a septic clinical picture with abdominal pain. A CT scan showed two abdominal collections with transgastric pancreatic stents correctly placed. The patient was diagnosed of acute relapse over chronic pancreatitis and percutaneous drainage of both collections was performed. In order to rule out origin of those collections from the EWG, the transgastric fistula was cannulated showing no leakage and improvement of the pancreatic head stenosis. Three plastic pancreatic stents were placed through the gastric wall into the pancreatic duct. The patient remains asymptomatic 40 months after initial EWG. Conclusion: In our experience, the EWG offers good clinical long-term outcomes in patients with high surgical risk.

Endoscopic nasogallbladder tube or stent placement in acute cholecystitis: a preliminary prospective randomized trial in Japan (with videos)

There are currently no prospective, controlled trials of endoscopic transpapillary gallbladder drainage in patients with acute cholecystitis. We evaluated the technical success rate and efficacy of endoscopic transpapillary gallbladder drainage by using either endoscopic nasogallbladder drainage (ENGBD) or endoscopic gallbladder stenting (EGBS) for patients with acute cholecystitis. Randomized, controlled study. Tertiary-care referral centers. Seventy-three consecutive patients with acute cholecystitis were randomized. ENGBD by using a 5F or 7F tube (n= 37) or EGBS (n= 36) by using a 7F stent. Technical success, clinical success, adverse events, and procedure-related pain score. The overall technical success rates in the ENGBD and EGBS groups were 91.9% and 86.1%, respectively (P > .05). The mean procedure times of ENGBD and EGBS were 20.3 ± 12.1 and 22.2 ± 14.5 minutes, respectively (P > .05). The overall clinical success rates by per protocol analysis were 94.1% and 90.3% in the ENGBD and EGBS groups, respectively, whereas the rates by intention-to-treat analysis were 86.5% and 77.8%, respectively (P > .05). Moderate adverse events were observed in the ENGBD (n= 2) and EGBS (n= 1) groups. The mean visual analog score of postprocedure pain in the ENGBD group was significantly higher than that in the EGBS group (1.3 ± 1.1 vs 0.4 ± 0.8, respectively; P< .001). Small sample size and the participation of multiple endoscopists who may have different levels of experience in endoscopic transpapillary gallbladder drainage. Both ENGBD and EGBS appear to be suitable for the treatment of acute cholecystitis in patients who are poor candidates for emergency cholecystectomy. ( UMIN000012316.).

Colic and gastric over-the-scope clip (Ovesco) for the treatment of a large duodenal perforation during endoscopic retrograde cholangiopancreatography.

Successful management of endoscopic retrograde cholangiopancreatography (ERCP)-related duodenal perforations, up to 20 mm, has been reported using several endoscopic devices [Von Renteln et al. 2010; Buffoli et al. 2012; Dogan et al. 2013; Donatelli et al. 2013; Meduri et al. 2014], however, surgery remains the standard of care management of larger defects [Wu et al. 2006; Lee et al. 2013]. Here we report, to the best of the authors’ knowledge, the first case of successful treatment of a large duodenal perforation (>20 mm) during ERCP, using several Ovesco clips. A 66-year-old white man was addressed for biliary drainage due to important cholestasis secondary to a liver metastatic lesion of an urothelial cancer treated by surgery and chemotherapy. During ERCP and while delivering the third plastic 10F stent (Figure 1) a movement of the endoscope provoked a large retroperitoneal duodenal perforation occupying 1/3 of the duodenal wall (Figure 2), opposite to the papilla at the early beginning of second duodenum. The size of perforation was important, mostly because the duodenal wall is thin and injury provoked a mucosal laceration with tearing of the wall. The decision to deliver a plastic stent instead of a metal one was taken given the poor prognosis of the patient, and namely because the stenosis was evaluated as ‘Bismuth IV’, and in the case of no improvement of liver function tests, a radiological percutaneous transhepatic approach would be compromised. Then the duodenoscope together with the partially delivered stent were immediately retrieved. A standard gastroscope loaded with an 11t Ovesco (OTSC®; Ovesco Endoscopy GmbH, Tubingen, Germany), under CO2 insufflation, was introduced but unfortunately the duodenal tear was too large, both in length and width, making it impossible to aspirate both edges of the tear in the cap or approach using a Twin Grasper®. A coloscope loaded with a 14t Ovesco was subsequently introduced and endoscopic suturing was started between the greater omentum and one edge of the duodenal tear (Figure 3). Since a closure defect persisted at the other end as shown after contrast-medium injection (Figure 4), the gastric Ovesco was delivered while aspirating the omentum incarcerated between the first colic clip and the free edge of the perforation, achieving full closure without contrast-medium extravasation (Figure 5). A nasogastric tube was left in place in soft aspiration. The patient was then transferred to the intensive care unit (ICU), for surveillance, where he remained for 7 days before being discharged. During his stay in the ICU, no fever was detected, the liver function tests were improved, and no further ERCP was needed to add the third stent. We only noticed a transient rise of the C-reactive protein, before its complete normalization, and CT scan as well as water-soluble contrast upper-studies performed on days 2 and 5 postoperatively were normal (Figure 6). Oral nutrition was started on day 6. At 1 month after endoscopy, the patient is fully asymptomatic. Figure 1. Hilar stenosis with 2 plastic stents in place. The guidewire in the left duct is about be placed, in order to deliver the third stent. Figure 2. Large duodenal defect. Figure 3. Colic clip Ovesco in place incarcerating greater omentum. Figure 4. Contrast-medium extravasation at the one end of the duodenal perforation despite colic Ovesco placement, given the large size of the defect. Figure 5. Watertight closure achieved using a ‘bridge technique’ using Ovesco on Ovesco. Figure 6. CT scan showing clips in place with no extravasation of contrast medium. In conclusion OTSC is a surgery-sparing device, and colic and gastric clips together can be a useful tool for the closure of large duodenal defects. However, the use of a colic Ovesco should be considered too, mainly because of its size, for upper gastrointestinal interventions in an expert’s hands.

Acute pancreatitis complicated by an abdominal mass

A 54-year-old woman with a history of alcohol abuse was seen at our clinic with abdominal discomfort, bloating, early satiety, and a weight loss of 30 pounds (13.6 kg). She had an episode of acute pancreatitis 3 months earlier. A visible epigastric mass (A) was identified on physical examination; it was round, smooth, firm, and nontender. There was no appreciable hepatomegaly or splenomegaly, and the mass was dull to percussion. CT showed a septated pseudocyst, measuring 19 × 17 cm (B, yellow arrow) causing severe compression of the stomach (B, white arrow). An EUS-guided cyst-gastrostomy was performed (C), and two double-pigtail 7F stents were placed across the gastric wall to establish pseudocyst drainage. The patient reported immediate symptomatic relief while in recovery, and her abdomen had become visibly flattened. Eight weeks later she reported resolution of all her symptoms, and her physical examination was unremarkable (D). Follow-up CT confirmed resolution of the large pseudocyst and normal expansion of the stomach. The stents were removed, and an ERCP confirmed no leaks or strictures involving the pancreatic duct.

Necessity of a Repeat Cholangiogram During Biliary Stent Removal after Post-cholecystectomy Bile Leak?

Purpose: To assess the need for repeat ERC (endoscopic retrograde cholangiography) in patients with biliary stent placed for post-cholecystectomy bile leak. Methods: A retrospective analysis of the CORI (Clinical Outcomes Research Initiative) database at Penn State Milton S Hershey Medical Center identified all patients referred for ERC for post-cholecystectomy bile leak from Jan 2001-June 2010. We collected baseline demographics, location of bile leak, size of biliary stent placed, duration of stenting, bile leak persistence, and the presence of stone, sludge or strictures on repeat ERC. Results: Total of 81 patients underwent ERC for management of bile leaks after cholecystectomy. One was excluded as he had a complete transection of the CBD and taken to the OR immediately. Fourteen (17.5%) patients had open cholecystectomy, 46 (57.5%) had laparoscopic and 10 (12.5%) had a laparoscopic converted to open. Of the 80 patients, 47 (58.7 %) had a Cystic duct leak, 11 (13.7 %) had a Right hepatic duct leak, 11 (13.7%) had CBD leak, 5 (6.2%) had a GB fossa leak, 4 (5%) had CHD leak and the other 2 (2.5%) had Left Hepatic duct leak. All 80 patients (100%) had a biliary stent placed. 57 of 80 (71.2%) had a 10F stent placed with the remainder having a 7F placed. Seventy-five (93.7 %) patients also underwent biliary sphincterotomy at the same time. Sixty-nine patients (11 had no repeat cholangiogram but clinically the leak had resolved) underwent repeat ERC after a mean duration of 8.2 weeks. Three had an early ERC due to suspicion for cholangitis and hence excluded from the analysis. Of the 66 included in the final analysis, 61 (92.4 %) had resolution of the bile leak on repeat ERC. All patients had a resolution of their bile leak by the third ERC. Fifteen patients (22.7 %) had an abnormality on repeat cholangiography (persistent leak in 4, stones in 3, sludge in 7, and leak + stone in 1) that required further intervention including balloon sweep, or further stenting. Conclusion: Although the majority of post cholecystectomy bile leaks resolve after biliary stent placement, a sizeable percentage of patients still have abnormalities on the subsequent cholangiogram that requires further endotherapy. These findings support the need for a repeat ERC +/- of balloon sweep at the time of biliary stent removal.

Sa1509 A Technique for Salvaging the Lost Stent At ERCP

Sa1509 A Technique for Salvaging the Lost Stent At ERCP

Endoscopic management of laparoscopic cholecystectomy‐associated bile duct injuries

The efficacy of the endoscopic management of laparoscopic cholecystectomy (LC)-associated bile duct injuries is unclear because few studies on the issue report methods matched to injury type or long-term follow-up data. Records from our institution's 11-year experience with the endoscopic management of LC-associated bile duct injuries were reviewed. Leakage was managed with a 5- to 7F endoscopic nasobiliary drainage (ENBD) tube for 1 week without endoscopic sphincterotomy (EST). Stricture was managed with the placement of a single 7F plastic stent for 1-2 months without EST. Fifteen cases were experienced. Of the 11 cases (77.8%) of leakage, 7 improved clinically and on imaging after ENBD, 2 did not resolve until after the placement of a single plastic 7F stent for several more days, and 2 others with leakage and high risk for accidental ENBD removal improved after the placement of a single 7F stent. All 4 cases of stricture resolved completely after the placement of a single 7F stent. There were no severe complications of the endoscopic procedure. At long-term follow-up, no patient had recurrence of symptoms or complications on imaging. ENBD for leakage and biliary stenting for strictures are safe and effective treatments for these LC-associated injuries.

Effect of Pancreatic Duct Stent Diameter on Hospitalization in Chronic Pancreatitis

Endoscopic therapy with pancreatic duct (PD) stenting in painful chronic pancreatitis is effective at reducing pain. Few studies have compared response to different PD stent diameters. In this study, we retrospectively analyzed the effect of PD stent diameter on hospitalization for abdominal pain in chronic pancreatitis. An existing database was queried to identify individuals who received PD stenting for chronic pancreatitis. Each patient was grouped according to stent diameter: (1) 8.5F stents or smaller and (2) 10F stents. The main outcome was number of hospitalizations adjusting for varying follow-up time and controlling for age, sex, and etiology of pancreatitis using a negative binomial model. One hundred sixty-three patients underwent PD stent placement for chronic pancreatitis from October 1995 to September 2007. One hundred twenty-nine patients (79%) received predominantly PD stents 8.5F or smaller in diameter, and 34 patients (21%) received predominantly PD stents 10F in diameter. There was no statistically significant difference in population characteristics between the 2 groups. The 10F stent group had a statistically significant (P = 0.003) lower rate of hospitalization. Patients who received larger diameter PD stents had fewer hospitalizations for abdominal pain. Outcome-based prospective studies are needed.

EUS for the management of peripancreatic fluid collections after distal pancreatectomy

Peripancreatic fluid collections (PFCs) are a common complication after distal pancreatectomy and are usually managed by percutaneous drainage. The role of EUS in the management of postoperative PFCs has not been previously reported. To evaluate the role of EUS in the management of PFCs after distal pancreatectomy. Case series. Academic tertiary referral center. Symptomatic patients with PFCs after a distal pancreatectomy. At EUS, the PFCs were accessed transgastrically by using a 19-gauge FNA needle and after passage of a 0.035-inch guidewire; sequential dilation of the transgastric tract was performed up to 8 mm and multiple 7F or 10F double-pigtail stents were deployed. Nasocystic drainage catheters were deployed in those with poor drainage at the time of endoscopy. To evaluate the technical and treatment success and safety profile of the EUS-based approach for management of PFCs after distal pancreatectomy. Ten patients (6 men, 4 women; mean age, 56.8 years [range 20-76 years]) underwent EUS-guided drainage of PFCs after distal pancreatectomy over a 30-month period. Indications for distal pancreatectomy were neuroendocrine tumor in 5 patients, focal chronic pancreatitis in 2, cyst neoplasm in 1, adenocarcinoma in 1, and trauma in 1. The mean size of the PFCs (largest dimension) was 91.4 mm (range 45-140 mm). EUS-guided drainage was technically successful in all 10 patients; 1 patient underwent EUS-guided drainage of 2 large noncommunicating PFCs in the same endoscopy session. Treatment was successful in 9 (90%) of 10 patients; 1 patient had persistent symptoms requiring reoperation. No procedural complications were encountered. At a mean follow-up of 151 days (range 96-280 days), all 9 patients were doing well without any evidence of symptom recurrence. Small number of patients and lack of a comparative treatment group. EUS-guided drainage is a minimally invasive, safe, and highly effective technique for the management of symptomatic PFC after distal pancreatectomy.

A Protocol of Multiple Side By Side Stenting of Symptomatic Common Bile Duct Strictures Secondary to Pancreatitis - Long Term Outcome

Background: Common bile duct strictures occur in 1/3 of patients with chronic pancreatitis. Although often asymptomatic, they may be associated with jaundice, abdominal pain or cholangitis. Early symptomatic stricture recurrence occurs with single biliary stent treatment. Operative management is advocated but carries potential morbidity and mortality. Incremental side by side stenting is well established for biliary strictures following bile duct injury, however data on long term outcome is lacking in pancreatitis related biliary strictures. Methods: Patients with symptomatic distal biliary stricture secondary to pancreatitis were managed by a standardized protocol of serial incremental side by side stenting with the therapeutic goal of at least three 10F straight biliary stents. Initial management consisted of repeat ERCP every 6-8 weeks placing maximal number of stents safely possible at each occasion. Once the target number of stents was achieved, ERCP and stent exchange was performed every 3/12 for a further 6-9 months before complete stent removal. All patients had complete stricture resolution on cholangiogram at final stent removal procedure. Data collection included symptoms pre and post stent protocol, liver function tests (LFTs) and radiological findings. Results: Over 7 years, 19 patients (mean age 52 years (range 39-77), males 17) with symptomatic biliary strictures secondary to pancreatitis were managed. Severe necrotizing pancreatitis preceded the symptomatic strictures in 5. Indications for endoscopic intervention were deranged LFTs/jaundice(9), abdominal pain(7) and cholangitis(3). Etiology of pancreatitis included alcohol(11), gallstone(3), idiopathic(3). 14/19 patients have completed the protocol - all achieved at least 3 side by side 10F stents, with maximum treatment of 4 stents in 2, and 5 in 1. 13 patients are in long term follow up - mean 37 months(range 11-56). 12 patients (92.3%) have not required repeat intervention, stricture recurrence occurred in 1 patient at 12 months. Abdominal pain resolved in 6/7 patients with predominant symptoms at study entry. Biochemical abnormalities improved with significant decline in ALP and GGT (p<0.05), LFTs normalised in 6. No patient required surgical intervention. No procedural complications were encountered. Conclusions: Multiple side by side stents is an effective treatment for pancreatitis related symptomatic biliary strictures. During long term follow up the response is durable in the majority of patients and therefore is a viable alternative to surgery.

Cholangiographic features of suppurative cholangitis

A 32-year-old man developed right upper quadrant RUQ) pain, fever, and jaundice 10 days after laparotomy nd resection of a 3-cm jejunal GI stromal tumor (GIST). Abominal US revealed a dilated common bile duct (CBD), ith biliary sludge as the likely cause for cholangitis. ERCP howed a dilated CBD with irregular ridging or serration f the CBD wall (A). After sphincterotomy, purulent bile nd thick sludge were cleared. A 10F plastic stent was placed o ensure continued adequate drainage. Follow-up ERCP at weeks showed complete resolution of the previous cholngiographic abnormalities (B). A 65-year-old man with fever, jaundice, and RUQ pain, unesponsive to parenteral antibiotics, underwent an emerency ERCP. Cholangiography revealed dilatation and rregular ridging or serration of the CBD wall (C). After phincterotomy, purulent bile as well as small CBD calculi ere cleared from the duct. A double-pigtail 7F stent was nserted for biliary drainage. Repeat ERCP after 6 weeks revealed resolution of the documented bile–duct-wall abnormality; however, a previously unapparent distal CBD stricture was found, and, subsequently, the diagnosis of cholangiocarcinoma was made (D).

PANCREATIC STENT-INDUCED DUCTAL INJURY

Background: Pancreatic duct (PD) stent placement is increasingly performed for prevention of post-ERCP pancreatitis. PD stents can result in injury especially in normal ducts, but the clinical significance and outcomes of subsequent endoscopic therapy are unknown. Methods: Patients included all those referred for management of stent-induced PD injury. All pts had initially normal PD diameter without evidence of chronic pancreatitis, and all PD stents were placed for prevention of post-ERCP pancreatitis. Results: 7 pts were referred for symptomatic PD stent-induced duct injury. At initial outside ERCP, all had normal PD anatomy (n = 5) or pancreas divisum (n = 2). All but one had conventional polyethylene 5F (n = 6) or 7F (n = 1) stents <4 cm in length in place for <2 weeks. At presentation 71% had acute recurrent pancreatitis, and 43% were on daily narcotics. All had a PD stricture within 2cm of major or minor papilla and 71% upstream PD dilation. 40% had new EUS evidence of chronic pancreatitis. Treatment included pancreatic sphincterotomy, balloon dilation of stricture, and placement of multiple 3-5F soft polymer pancreatic stents; all but one required multiple ERCPs for therapy. All had improvement or resolution of pancreatic strictures. 4/7 had resolution of pain, 1/7 fair response with repeated ERCPs, and 2/7 required total pancreatectomy. Conclusions: PD stent-induced ductal injury with significant clinical consequences can occur with conventional polyethylene stents. Endoscopic therapy is moderately effective but some patients develop irreversible damage.

Single-step EUS-guided transmural drainage of simple and complicated pancreatic pseudocysts

Single-step EUS-guided transmural drainage of pseudocysts has been reported, but there are no published prospective studies on clinical outcomes. To assess the safety and the efficacy of single-step EUS-guided placement of large endoprostheses to treat simple and complicated pseudocysts. Prospective cohort study. Single tertiary referral center. Consecutive patients referred for management of symptomatic chronic pancreatic pseudocysts >4 cm in size. Single-step EUS-guided transmural pseudocyst drainage performed with a linear-array echoendoscope for placement of 10F stents in adults and 7F stents in children. Complete or partial (>50% reduction) resolution of pseudocyst on follow-up imaging, recurrence, clinical response, and procedure-related complications. Recurrence was defined as the reappearance of a pancreatic pseudocyst in the same location. There were 33 patients, with a mean age of 43 years. Median pseudocyst size was 8.5 cm (range, 4-20 cm). Fourteen patients (42%) had infected pseudocysts, 8 patients (24%) had gastric varices, and 16 patients (48%) had no visible endoscopic bulge. Stent placement was successful in 31 patients (94%). Twenty-seven patients (82%) had complete resolution of a pseudocyst; 4 patients (12%) had partial resolution, with symptom relief. There were 2 major complications and 3 minor complications. Recurrence of a pseudocyst was observed in only 1 patient over a median follow-up of 46 weeks. No randomized treatment arm comparing this technique with conventional endoscopic drainage. Single-step EUS-guided transmural drainage with large endoprostheses is a safe and effective therapy for patients with simple and complicated pancreatic pseudocysts.