Biliary Stent Dysfunction Research Articles

Palliation of Gastric Outlet Obstruction in Case of Biliary Obstruction-A Retrospective, Multicenter Study: The B-GOOD Study.

EUS-guided gastroenterostomy (EUS-GE) is a novel and effective procedure for the management of malignant gastric outlet obstruction (GOO) with more durable results when compared to enteral stenting (ES). However, data comparing EUS-GE to ES in patients already treated with EUS-guided choledocoduodenostomy (EUS-CDS) for distal malignant biliary obstruction (DMBO) are lacking. We aimed to compare outcomes of EUS-GE and ES for the palliation of GOO in this specific population of patients. A multicenter, retrospective analysis of patients with DMBO treated by EUS-CDS and subsequent GOO treated by EUS-GE or ES from 2016 to 2021 was conducted. Primary outcomes were overall AEs rate and dysfunction of the EUS-CDS after GOO treatment. Secondary outcomes included clinical success, technical success, procedure duration, length of hospital stay and relapse of GOO symptoms. A total of 77 consecutive patients were included in the study: 25 patients underwent EUS-GE and 52 underwent ES. AEs rate and patency outcomes of the EUS-CDS after GOO treatment were comparable between the two groups (12.5% vs. 17.3%; p = 0.74). No recurrence of GOO symptoms was registered in the EUS-GE group while 11.5% of ES patients had symptoms recurrence, even if not statistically significant (p = 0.16), after a mean follow-up period of 63.5 days. EUS-GE and ES are both effective and safe for the palliation of GOO in patients already treated by EUS-CDS for DMBO with no difference in the biliary stent dysfunction rate and overall AEs. EUS-GE is associated with less recurrence of GOO symptoms.

Percutaneous Metallic Stents in Malignant Biliary Obstruction: Comparison of Nitinol and Wall Stents.

Palliation of malign biliary obstruction is important which is commonly carried out by percutaneous biliary stenting. Our primary aim with this study was assessment of performance of wall stents, and nitinol stents for the palliation of malign biliary obstruction. The medical records of 157 patients who underwent biliary stenting in our department between January 1, 1995, and December 31, 2005, were retrospectively analyzed. Technical success, treatment success, mortality in the first 30days, minor, and major complications were evaluated and compared among the wall stent, and the nitinol stent groups in all patients which constituted the primary study endpoints. Additionally, stent patency, and mean patient survival times after stent implantation were evaluated in patients for whom follow-up information could be obtained. A total of 213 metallic stents were placed in 157 patients. Wall stent was placed in 83 of the patients with mean age, and SD of 60.4 and 13.5. Nitinol stent was placed in 74 of the patients with mean age of 57.8, and SD of 15.5. Gender ratio was equal in both groups. Biliary stent dysfunction was observed in 13 patients in each of nitinol, and wall stent groups throughout the study period. There was no statistical difference among re-occlusion rates (p = 0.91). For the nitinol stent group median primary patencytime was 119days (90-185days CI 95%), and for the wall stent group median primary patencytime was 81days (60-150days CI 95%). Nitinol stents, and wall stents are safe options that can be safely used in the percutaneous treatment of malignant biliary obstruction with similar treatment and therapeutic success, low complication rates, and patency times that can extend beyond expected survival times.

Clinical application of the retrograde track method in reopening dysfunctional biliary stents.

Biliary stent dysfunction is challenging to treat in clinic. The retrograde track method (RTM) has a promising clinical application in the reopening of dysfunctional biliary stents. This study aimed to evaluate the clinical value of the RTM in reopening dysfunctional biliary stents. From February 2013 to January 2020, 151 patients underwent percutaneous transhepatic biliary interventional procedures for reopening dysfunctional biliary stents at the First Affiliated Hospital of Zhengzhou University, and 25 patients (12 females, 13 males; mean age 63.12 years old) underwent the RTM after anterograde reopening dysfunction biliary stent failure. Technical success, clinical success, irradiation dose, procedure time, complications, and overall survival (OS) were recorded, and levels of total bilirubin (TBIL), direct bilirubin (DB), alanine aminotransferase (ALT), albumin (ALB), and carbohydrate antigen-199 (CA-199) were compared before treatment and 1 month after treatment. The technical and clinical success rates were 100% and 96%, respectively, and the irradiation dose and procedure times were 774.07±330.80 mGy and 45.16±9.48 min, respectively. Two patients (8%) experienced major complications. The median OS was 10.73 months [95% confidence interval (CI): 9.37-12.09]. Compared with pretreatment values, the mean levels at 1 month after RTM administration for TBIL (189.47±59.20 vs. 44.65±16.12 µmol/L), DB (144.21±55.83 vs. 27.95±13.86 µmol/L), ALT (89.62±30.85 vs. 49.44±14.25 U/L), and CA-199 (584.59±269.82 vs. 176.76±100.68 U/mL) showed significant decreases, while that of ALB (36.32±2.05 vs. 40.22±1.95 g/L) showed a significant increase (all P values <0.05). RTM is an effective alternative treatment method when anterograde reopening of a dysfunctional biliary stent occurs.

Percutaneous insertion of long-covered biliary stents in patients with malignant duodenobiliary stricture.

To investigate the technical feasibility, safety, and efficacy of a long-covered biliary stent in patients with malignant duodenobiliary stricture. This retrospective study enrolled 57 consecutive patients (34 men, 23 women; mean age, 64years; range, 32-85years) who presented with malignant duodenobiliary stricture between February 2019 and November 2020. All patients were treated with a long (18 or 23cm)-covered biliary stent. The biliary stent deployment was technically successful in all 57 patients. The overall adverse event rate was 17.5% (10 of 57 patients). Successful internal drainage was achieved in 55 (96.5%) of 57 patients. The median patient survival and stent patency times were 99days (95% confidence interval [CI], 58-140days) and 73days (95% CI, 60-86days), respectively. Fourteen (25.5%) of the fifty-five patients presented with biliary stent dysfunction due to sludge (n = 11), tumor overgrowth (n = 1), collapse of the long biliary stent by a subsequently inserted additional duodenal stent (n = 1), or rapidly progressed duodenal cancer (n = 1). A univariate Cox proportional hazards model did not reveal any independent predictor of biliary stent patency. Percutaneous insertion of a subsequent biliary stent was technically feasible after duodenal stent insertion. Percutaneous insertion of a long-covered biliary stent was safe and effective in patients with malignant duodenobiliary stricture. In patients with malignant duodenobiliary stricture, percutaneous insertion of a long-covered biliary stent was safe and effective regardless of duodenal stent placement. • Percutaneous insertion of long-covered biliary stents in patients with malignant duodenobiliary stricture is a safe and effective procedure. • Biliary stent deployment was technically successful in all 57 patients and successful internal drainage was achieved in 55 (96.5%) of 57 patients. • The median patient survival and stent patency times were 99days and 73days, respectively, after placement of a long-covered biliary stent in patients with duodenobiliary stricture.

Long-term outcomes of duckbill-type anti-reflux metal stents versus conventional covered metal stents in reinterventions after covered biliary metal stent dysfunction in unresectable pancreatic cancer.

The use of duckbill-type anti-reflux metal stents (DMS) in reinterventions after covered metal stent (CMS) dysfunction has been reported in patients with distal malignant biliary obstruction (MBO). However, the superiority of DMS over conventional CMS (c-CMS) has not been established. Therefore, we conducted this retrospective study to evaluate the long-term efficacy and safety of DMS as a second stent in comparison with c-CMS. We investigated consecutive patients with distal MBO due to unresectable pancreatic cancer who underwent reintervention after dysfunction of initial biliary CMS at our institution. We compared causes of recurrent biliary obstruction (RBO), time to RBO (TRBO), adverse events (AEs), and reintervention rates of DMS and c-CMS in this stenting. A total of 76 patients were included (DMS 41 and c-CMS 35). While overall RBO rates were similar between the two groups (46% vs. 63%, p = 0.172), RBO due to non-occlusion cholangitis tended to be less frequent in the DMS group than in the c-CMS group (2% vs. 14%, p = 0.089). Median TRBO was significantly longer in the DMS group (286days vs. 112days, p = 0.029). DMS was identified as the only significant risk factor for TRBO (hazard ratio, 0.52; p = 0.044). Overall AE rates were significantly lower in the DMS group (2% vs. 23%, p = 0.010), with non-occlusion cholangitis being the most common AE in the c-CMS group. Endoscopic reintervention was successfully performed in all patients in both groups, despite failed stent removal in 15% of patients in DMS group. DMS was associated with a significantly longer TRBO and lower rate of AEs compared with c-CMS in reinterventions after initial CMS dysfunction. DMS may be preferable to c-CMS as a second stent after biliary CMS dysfunction.

Transpapillary biliary drainage using a long plastic stent: Preventing early stent dysfunction in pancreatic cancer with duodenal invasion.

Highlight Duodenal invasion has been reported to be a risk factor for early biliary stent dysfunction in patients with pancreatic cancer. Mandai and colleagues describe their method of transpapillary biliary drainage using a long plastic stent as a potentially useful treatment option to avoid early stent dysfunction in such patients.

Efficacy and safety of endoscopic retrograde cholangiopancreatography in the very elderly by using a combination of intravenous midazolam, ketamine and pethidine.

The number of therapeutic endoscopic procedures in elderly individuals keeps increasing and this population has a high risk of adverse events related to sedation and general anesthesia. However, there is a paucity on data about the efficacy and safety of endoscopic retrograde cholangiopancreatography (ERCP) in this population. In total, 417 consecutive ERCP procedures were performed in 362 patients between September 2018 and January 2020. Of these, 59 patients (74 sessions) were aged ≥80 years (Group A) and 173 patients (193 procedures) were aged ≤65 years (Group B). We analyzed the prospectively collected data of patient- and procedure-related variables. The procedure time was significantly longer in Group A (P < 0.05). The prevalence of comorbidities, use of anticoagulants and American Society of Anesthesiologists (ASA) physical status classification levels were significantly higher in Group A (P < 0.05). The incidence of periampullary diverticula, malignancy, rate of difficult cannulation, mean number of stones, use of biliary stents and stent dysfunction was also significantly higher in Group A (P < 0.05). The medication doses used were significantly higher and emergence symptoms were significantly more frequent in Group B (P < 0.05). The rates of bleeding, pancreatitis, perforation, cholangitis, hypoxia, hypotension and the length of hospital stay did not significantly differ between the two groups. The overall success rate of the procedure was comparable in the two groups (P=0.874). ERCP can be safely performed in elderly patients using a combination of midazolam and ketamine without propofol. The incidence of complications is comparable with that observed in younger patients. Geriatr Gerontol Int 2021; 21: 887-892.

Percutaneous solutions for biliary stent dysfunction: pictorial essay.

Plastic and metal biliary stents can fail to function properly, such failure being due to a positioning error or to the migration, occlusion, or fracture of the stent. An obstructed biliary stent can act as a nidus, causing complications such as recurrent persistent cholangitis. It can also cause vascular complications (such as bleeding and the formation of pseudoaneurysms), perforate the liver capsule (causing biloma or abscess), or, in rare cases, cause intestinal obstruction or perforation. In this pictorial essay, we demonstrate various interventional radiology techniques for the treatment of biliary stent dysfunction in patients with obstructive biliary disease.

Lumen apposing metal stents versus tubular self-expandable metal stents for endoscopic ultrasound-guided choledochoduodenostomy in malignant biliary obstruction.

EUS-guided choledochoduodenostomy (EUS-CDS) is an effective option for biliary drainage in malignant biliary obstruction. Lumen apposing metal stents (LAMS) are increasingly been used for EUS-CDS. It is unknown how LAMS compare to tubular self-expandable metal stents (SEMS) for EUS-CDS. Our aim is to compare the clinical outcomes of LAMS versus SEMS for EUS-CDS. Single-center retrospective cohort study of consecutive patients with unresectable malignant biliary obstruction who underwent EUS-CDS after failed ERCP for initial biliary drainage between 2011 and 2019. Clinical outcomes were compared between patients who had conventional covered SEMS and LAMS placed for EUS-CDS. Outcome measures included unplanned procedural events, technical success, clinical success, adverse events and reinterventions. Survival was analyzed by the Kaplan-Meier method. During the study period 57 patients met inclusion criteria (37 LAMS, 20 SEMS). All EUS-CDS were technically successful (LAMS group 95% CI 90.3-100%, SEMS group 95% CI 83.2-100%). There were no differences between groups in unplanned procedural events (4 LAMS deployment issues, 2 mild bleeding in SEMS group; 10 vs 10.8%), clinical success (37/37 [100%] vs 19/20 [95%]), and short-term adverse events (5/37 [13.5%] vs 4/20 [20%], p = 0.71). Complete follow-up data were available in 41 patients for a mean of 376 ± 145days. Endoscopic reintervention was required for duodenal stent placement (n = 9) or biliary stent dysfunction (n = 4), with no difference between LAMS and SEMS group (6/37 [16.2%] vs 7/20 [35%]). There were no differences in overall survival between both groups. EUS-guided choledochoduodenostomy after failed ERCP has equally high technical and clinical success rates with either LAMS or SEMS in patients with malignant biliary obstruction. No differences in adverse events, reinterventions and survival were seen with either type of stent. The cost-effectiveness of LAMS vs SEMS for EUS-guided choledochoduodenostomy remains to be proven.

Percutaneous Biliary Metallic Stent Insertion in Patients with Malignant Duodenobiliary Obstruction: Outcomes and Factors Influencing Biliary Stent Patency.

To investigate the technical and clinical efficacy of the percutaneous insertion of a biliary metallic stent, and to identify the factors associated with biliary stent dysfunction in patients with malignant duodenobiliary obstruction. The medical records of 70 patients (39 men and 31 women; mean age, 63 years; range, 38-90 years) who were treated for malignant duodenobiliary obstruction at our institution between April 2007 and December 2018, were retrospectively reviewed. Variables found significant by univariate log-rank analysis (p < 0.2) were considered as suitable candidates for a multiple Cox's proportional hazard model. The biliary stents were successfully placed in all 70 study patients. Biliary stent insertion with subsequent duodenal stent insertion was performed in 33 patients and duodenal stent insertion with subsequent biliary stent insertion was performed in the other 37 study subjects. The median patient survival and stent patency time were 107 days (95% confidence interval [CI], 78-135 days) and 270 days (95% CI, 95-444 days), respectively. Biliary stent dysfunction was observed in 24 (34.3%) cases. Multiple Cox's proportional hazard analysis revealed that the location of the distal biliary stent was the only independent factor affecting biliary stent patency (hazard ratio, 3.771; 95% CI, 1.157-12.283). The median biliary stent patency was significantly longer in patients in whom the distal end of the biliary stent was beyond the distal end of the duodenal stent (median, 327 days; 95% CI, 249-450 days), rather than within the duodenal stent (median, 170 days; 95% CI, 115-225 days). The percutaneous insertion of the biliary metallic stent appears to be a technically feasible, safe, and effective method of treating malignant duodenobiliary obstruction. In addition, a biliary stent system with a distal end located beyond the distal end of the duodenal stent will contribute towards longer stent patency in these patients.

Efficacy and safety of chemotherapy after endoscopic double stenting for malignant duodenal and biliary obstructions in patients with advanced pancreatic cancer: a single-institution retrospective analysis

BackgroundAdvanced pancreatic cancer is accompanied not only by bile duct obstruction, but also occasionally by duodenal obstruction. With new advances in chemotherapy and improvement in the management of stent dysfunction, the life expectancy of patients with pancreatic cancer has increased. This study aimed to evaluate the efficacy and safety of chemotherapy for advanced pancreatic cancer, as well as to analyze the prognostic factors, following endoscopic double stenting.MethodsThis retrospective study was conducted from January 1, 2007 to October 31, 2015 at an academic center. Fifty consecutive patients with pancreatic cancer who had undergone endoscopic double stenting, comprising duodenal and biliary stenting, were analyzed. We reviewed the patients records and analyzed the data of stent dysfunction rates after double stenting, reintervention for stent dysfunction, chemotherapy after double stenting, adverse events associated with chemotherapy after double stenting, survival times following double stenting, and overall survival times. The hospital’s institutional review board for human research approved this study.ResultsThe overall survival time and the survival time following double stenting were 10.9 months (IQR 6.0–18.4 months) and 2.4 months (IQR 1.4–5.2 months), respectively. After double stenting, duodenal stent dysfunction occurred in 6 patients (12%), and biliary stent dysfunction occurred in 12 patients (24%), respectively. All patients who experienced stent dysfunction underwent endoscopic reintervention, and all of the procedures were successful. Twenty-one (42%) patients were treated with chemotherapy post double stenting; 9 patients received chemotherapy as a first-line treatment, 9 as a second-line treatment, and 3 as a third-line treatment. During chemotherapy, 8 (38%) patients had grade 3–4 adverse events, which were manageable. Chemotherapy post double stenting (OR, 0.19; 95% CI, 0.059–0.60; P = .0051), reintervention for biliary stent dysfunction (OR, 0.21; 95% CI, 0.081–0.50; P = .0002), and performance status (< 2) (OR, 0.28; 95% CI, 0.098–0.71; P = .0064) were significant prognostic factors after double stenting.ConclusionsSystemic chemotherapy was manageable, even in patients with double stenting. Chemotherapy after double stenting and appropriate reintervention for stent obstructions potentially prolonged the survival of patients with advance pancreatic cancer.

Endoscopic Gastrojejunostomy: An Evolving Approach for the Treatment of Gastric Outlet Obstruction

Gastric outlet obstruction (GOO) can occur due to variety of etiologies, both malignant and benign. The treatment of GOO has evolved over the years, based on etiology, from surgical to an ever-growing choice of endoscopic therapies. We present an 81-year-old man with a history of stage 3 pancreatic adenocarcinoma being treated with a combination of chemotherapy and radiation therapy. He developed biliary obstruction, for which a biliary metal stent was placed 11 months prior to his admission. He presented with two weeks of post prandial nausea and emesis and a resultant intolerance for solid food and thick liquids. He was doing well with good functional status prior to these symptoms. The patient underwent EGD which revealed a severe stenosis at the second portion of the duodenum in the region of the biliary stent with a large ulcer in the area as well. Due to the presence of the large ulcer and a desire to maintain access to the biliary tree the option of a gastrojejunostomy (GJ) was offered. First a long catheter was placed over a wire and left in the distal duodenum to allow for distension with a methylene blue/contrast solution as needed. Using a linear array echoendoscope the distended bowel loop was identified and punctured with a 22 gauge FNA needle and blue fluid was aspirated to confirm position. Using a cautery-enhanced LAMS system a GJ was successfully created with a 15 mm LAMS at the greater curvature of the stomach. The lumen of the stent was then dilated to 15 mm with a balloon. The patient was able to tolerate clear liquids well and was discharged the next day. While a surgical GJ is the preferred management of GOO it is associated with a high rate of complications. Enteral stenting has proven to be an effective alternative, however stent obstruction can occur in about 18% of cases with reported patency rates as low as 57% at 6 months in one series. In patients with biliary metal stents, the subsequent placement of a duodenal stent has been shown to be a risk factor for biliary stent dysfunction. Recent data has demonstrated the feasibility and short-term efficacy of EUS-GJ and offers an intriguing alternative to current options. Potential advantages may prove to be maintained access to the biliary tree and perhaps longer clinical success. While more prospective data is needed regarding the long term efficacy and safety of the technique, it may be a reasonable alternative in certain clinical scenarios.Figure: EUS view of distended loop of small intestine in close proximity to the gastric wall.Figure: Endoscopic view of loop of small intestine through LAMS.Figure: Fluoroscopic image of deployed LAMS forming a gastrojejunostomy.

Long‐term outcomes and risk factors of biliary stent dysfunction after endoscopic double stenting for malignant biliary and duodenal obstructions

Few reports describe the endoscopic double-stenting procedure for malignant biliary and duodenal obstructions. We evaluated the clinical outcomes from double stenting, and analyzed the risk factors for biliary stent dysfunction following double stenting. Eighty-one patients who underwent endoscopic double stenting for malignant biliary and duodenal obstructions were retrospectively analyzed. We determined the stent dysfunction rate and the biliary stent dysfunction risk factors, and analyzed the endoscopic reintervention results. Overall survival time and survival time following double stenting were 365 (38-1673) days and 73 (20-954) days, respectively. After double stenting, the 3-month and 6-month duodenal stent dysfunction rates were 14% and 41%, respectively. Reintervention technical success rate was 100% (10/10), and mean gastric outlet obstruction scoring system scores improved from 0.7 to 2.4 points (P < 0.001). The 3-month and 6-month biliary stent dysfunction rates were 26% and 41%, respectively. The reintervention technical and clinical success rates were 95% (20/21) and 81% (17/21), respectively. Risk factors for biliary stent dysfunction following double stenting were events associated with duodenal stent dysfunction (odds ratio [OR], 11.1; 95% confidence interval [CI], 2.09-87.4; P = 0.0044) and the biliary stent end's location (OR, 6.93; 95% CI, 1.37-40.2; P = 0.0019). Some patients had stent dysfunction irrespective of the survival period after double stenting. Endoscopic reintervention was technically feasible and clinically effective even after double stenting. Duodenal stent dysfunction and biliary stent end's location were risk factors for biliary stent dysfunction.

Application of a silver coating on plastic biliary stents to prevent biofilm formation: an experimental study using electron microscopy.

Background and study aims: Biliary stent dysfunction is mainly caused by biliary sludge that forms as a result of bacterial adherence and subsequent biofilm formation on the inner surface of the stent. Silver ions arewell known to have excellent antimicrobial activity against a wide range of microorganisms. In this study, we designed and constructed silver-coated plastic stent (PS) and investigated whether the silver coating prevented bacterial adherence and biofilm formation through the use of electron microscopy. Material and methods: The polyurethane PS with/without silver coating were prepared in 6-inch segments. The silver-based antimicrobial agents were electrostatically applied onto the stent surface. The stents were then immersed for 5 weeks in infected human bile juice obtained from a patient with cholangitis, and electron microscopy was used to investigate the ability of the modified PS to prevent bacterial adherence and biofilm formation. Results: The bacterial flora did not change before and after immersion of stents in both the group with and without silver coating. Electron microscopic observation revealed meshwork-like structures around the bacteria, characteristic of biofilm-forming bacteria, in all stents from the control group (6/6, 100 %). On the other hand, a limited number of bacteria were observed in all stents in the silver-coated group, and no apparent biofilm formation was observed (0/6, 0 %). Conclusions: The significance of the findings from our study is the ability of silver-coated PS to prevent biofilm formation on the stent surface, which results in the prevention of stent occlusion.

Type of Combined Endoscopic Biliary and Gastroduodenal Stenting Is Significant for Biliary Route Maintenance.

Objective Some patients with malignant gastric outlet obstruction require combined biliary and gastroduodenal stenting (double stenting). However, biliary stent dysfunction can often disturb biliary route maintenance, thus making the optimal biliary stenting for these patients unclear. The present study was designed to assess the factors associated with the long-term maintenance of biliary drainage routes. Methods The clinical features and long-term outcomes were assessed in patients who underwent double stenting. Patients The outcomes were reviewed in 43 consecutive patients who successfully underwent endoscopic double stenting with metallic stents. Results An univariate analysis of all patients with biliary stent dysfunction showed the separate type of double stenting (two stents placed in a non-crossed position) to be the only predictive factor related to successful biliary re-intervention for stent dysfunction (odds ratio 73.67, p=0.001). A comparison of the clinical features in patients who underwent separate and cross (two stents placed in a crossed position) stenting showed the functional success rate to be higher for the separate (93.3%) than for the cross (61.5%) stent type, with the median times to biliary stent dysfunction differing significantly (330 vs. 298 days, respectively; p=0.048). The success rates of re-intervention in patients with separate and cross type stents were 88.9% and 0.0%, respectively (p=0.001), and the initial biliary route maintenance rates were 96.7% and 53.8%, respectively (p=0.002). Conclusion The separate type of double stenting may enhance successful biliary re-intervention for stent dysfunction and also maintain the initial drainage route longer. The biliary drainage outcomes should therefore be considered when choosing the type of double stenting.

Percutaneous biliary covered stent insertion in patients with malignant duodenobiliary obstruction

Although the use of polytetrafluoroethylene (PTFE)-covered biliary stents has proven to be feasible for the treatment of benign and malignant biliary disease, less is known regarding the outcomes of percutaneous placement of a covered stent in patients with malignant duodenobiliary obstruction. To investigate the technical and clinical efficacy of the percutaneous placement of a PTFE-covered biliary stent in patients with malignant duodenobiliary obstruction. From April 2007 to September 2012, the medical records of 45 consecutive patients with malignant duodenobiliary obstruction were retrospectively reviewed. All percutaneous biliary stent deployment was performed using PTFE-covered stents, whereas duodenal stent insertion was performed either fluoroscopically or endoscopically using covered or uncovered stents. Biliary stent deployment was technically successful in all patients. None of the stents migrated after deployment. Procedure-related minor complications, including self-limiting hemobilia, occurred in three (7%) patients. Successful internal drainage was achieved in 39 (87%) of the 45 patients. The median survival time after biliary stent placement was 62 days (95% confidence interval, 8-116 days), and the cumulative stent patency rates at 1, 3, 6, and 12 months were 96%, 92%, 75%, and 38%, respectively. The causes of biliary stent dysfunction included stent occlusion caused by a subsequently inserted duodenal stent (n = 7), food impaction (n = 3), and sludge incrustation (n = 1). One patient developed acute cholecystitis 131 days after biliary stent placement and underwent percutaneous transhepatic gallbladder drainage. Percutaneous insertion of a PTFE-covered stent is a safe and effective method for palliative treatment of patients with malignant duodenobiliary obstruction. If possible, subsequent biliary stent insertion is preferable in order to prevent possible biliary stent dysfunction caused by subsequent insertion of a duodenal stent.

Predictors of Organ Failure and Role of Early ERCP in Hospitalized Patients with Acute Cholangitis

Purpose: Acute cholangitis is considered a medical emergency and predictors associated with organ failure are not well defined. Furthermore, the impact of early endoscopic retrograde cholangiopancreatography (ERCP) on outcomes in hospitalized patients with cholangitis is unclear. The aim of the study is to examine clinical outcomes and identify predictors associated with persistent organ failure in hospitalized patients with acute cholangitis. Methods: Consecutive hospitalized patients who received ERCP at Loma Linda University Medical Center for suspected cholangitis between 4/2005-3/2013 were identified by reviewing an internal endoscopy database. Cholangitis was defined by radiographic evidence of biliary obstruction and signs of systemic infection (fever, leukocytosis, bacteremia, and/or purulent bile drainage during ERCP). Primary outcome was persistent organ failure at >48 hours from hospitalization (≥1.5 times rise in creatinine levels from baseline values to ≥1.5 mg/dL, or need for dialysis, mechanical ventilation, and/or hypotension requiring vasopressor). Results: A total of 167 patients who underwent ERCP for indication of suspected cholangitis met the inclusion criteria. The mean age was 60±19 years; 70% were male. On presentation, 86 (51%) patients demonstrated Charcot's triad, 58 (35%) had bacteremia, and ERCP was performed at a median of 41 hours (range, 0-927 hours) from hospitalization. The cause of cholangitis included common bile duct stone in 87 (52%) patients, biliary stent dysfunction in 46 (28%), and malignant stricture in 12 (7%). Initial biliary decompression with ERCP was accomplished in all but 11 patients (7%), and 4 (2%) developed ERCP associated complications (pancreatitis in three, post-sphincterotomy bleeding in one). Clinical outcomes of the 167 patients with cholangitis are shown in Table 1. On multivariate analysis, patients with Charlson Comorbidity Index >2 (odds ratio [OR] 14.0; 95% confidence interval [CI] 2.9-69.0; P=0.001) and 1-2 (OR 6.9; 95% CI 1.3-36.9; P=0.02) compared to zero, presence of systemic inflammatory response syndrome (SIRS; OR 3.7; 95% CI 1.6-8.7; P=0.002), and ERCP performed ≥48 hours (OR 3.2; 95% CI 1.4-7.9; P=0.006) compared to <48 hours from presentation were associated with persistent organ failure.TableConclusion: Delayed performance in ERCP was associated with persistent organ failure in hospitalized patients with acute cholangitis after adjusting for medical comorbidity and SIRS. Early ERCP performed <48 hours from presentation in patients with suspected cholangitis may improve outcomes.

Duodenal metal stent placement is a risk factor for biliary metal stent dysfunction: an analysis using a time-dependent covariate

Although the combination of biliary and duodenal self-expandable metal stents (SEMS) is useful, the exacerbating effect of duodenal SEMS placement on biliary SEMS has not been documented. We conducted a multicenter retrospective study to evaluate the effect of duodenal SEMS placement on biliary SEMS. Patients who underwent first-time biliary SEMS placement for a distal malignant biliary obstruction between September 1994 and November 2010 were included. Time to dysfunction of biliary SEMS was analyzed to identify risk factors for biliary SEMS dysfunction. Duodenal SEMS placement was analyzed as a time-dependent covariate. In total, 410 eligible patients were identified. Duodenal SEMS were placed in 33 patients (8 %). The median time to dysfunction of biliary SEMS was 170 days. Male gender (hazard ratio 1.37, 95 % confidence interval 1.03-1.83, P = 0.029) and duodenal SEMS placement (hazard ratio 2.00, 95 % confidence interval 1.16-3.45, P = 0.013) were risk factors in the multivariate Cox model. In patients undergoing duodenal SEMS, biliary SEMS dysfunction was observed in 17 (52 %) with a median time to dysfunction of 64 days after duodenal SEMS placement. As many as 60 % of the patients with biliary SEMS dysfunction after duodenal SEMS placement needed permanent percutaneous transhepatic biliary external drainage. Duodenal SEMS placement is a risk factor for biliary SEMS dysfunction. Alternative methods for biliary drainage should be considered for better biliary drainage in patients with a gastric outlet obstruction.

Efficiency of Combined EUS-FNA and Biliary or Duodenal Stenting in Patients with Non Operable Pancreatic Cancer

Background and Aims: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is essential in the workup of locally advanced and metastatic pancreatic cancer and can be coupled with ERCP during the same sedation/anesthesia when biliary and/or duodenal stenting are needed. This “tandem” procedure may be cost-effective and can reduce the length of hospital stay, but the efficiency and potential risks of this approach have not been clearly defined. The aim of this study was to investigate the efficiency and complications of EUS-FNA combined with biliary or duodenal stent placement during the same session. Methods: The cases of 97 consecutive patients referred to our center for suspected pancreatic cancer with biliary and/or digestive obstruction over a 36 months period were retrospectively studied. All patients had a locally advanced or metastatic pancreatic mass of unknown nature, were not eligible for surgery and underwent an EUS-FNA coupled with an ERCP with biliary and/or duodenal stenting within the same session. We collected histological results, clinical outcome data, complications, length of stay and timespan between endoscopic procedures and first chemotherapy treatment. Results: EUS-FNA and ERCP were performed under general anesthesia. The median procedure time was 75 minutes. A histological proof of cancer was obtained in 88% of patients after the initial EUS-FNA (100% after a second EUS-FNA). Biliary stent placement was successful in 98% and 5% had a biliary stent dysfunction and needed to undergo a second ERCP. All (5) patients with duodenal stenting had a soft or normal diet 48 hours. Procedure-related morbidity was 7% (1 case of pancreatitis, 2 cases of hemobilia, 1 case of sepsis and 5 cases of respiratory distress), but 4% (4 patients) died within 10 days of procedure from post-anesthesia complications. The mean hospitalization time after endoscopy was 13 days, including the first chemotherapy in 14% of patients. 64% of patients underwent chemotherapy within a median timespan of 20 days after endoscopic procedures. Conclusions: Combined EUS-FNA and stenting is feasible in nearly all patients with non-operable pancreatic cancer, with a high histological yield and rapid clinical recovery, allowing for prompt chemotherapy. However, a lengthy procedure and anesthesia can be harmful in the most-severely-ill patients.

Palliation in patients with malignant gastric outlet obstruction with a newly designed enteral stent: a multicenter study

Through-the-scope (TTS) stents facilitate palliative enteral stent placement. However, most TTS stents are braided, a characteristic that has been associated with significant foreshortening and relatively frequent migration. To evaluate clinical experience with a new woven enteral stent in the treatment of gastric outlet obstruction. From January 2005 to August 2006, patients with unresectable malignant gastric outlet obstruction were offered stent placement with a new woven stent. Three referral hospitals in Japan. Thirty-seven consecutive patients with malignant gastric outlet obstruction. A newly designed enteral stent was placed by using the TTS placement technique. Palliation efficacy and safety of the new stents. Stent placement was successful in 36 of 37 patients (technical success, 97%). Thirty-four patients were able to tolerate oral intake without obstructive symptoms (clinical success, 94.4%). Complications occurred in 16.2% of patients, comprising 2 cases of primary stent dysfunction, 1 perforation, 1 GI bleeding, 1 stent obstruction, and 1 biliary stent dysfunction. No migration was seen during the median follow-up period of 68 days. Small sample size and relatively brief follow-up. A newly developed enteral stent with higher flexibility and less foreshortening offers comparable clinical outcome to existing stents and a lower frequency of complications, including migration.