Covered Metal Stents Research Articles

S2555 Right Hepatic Artery Pseudoaneurysm: A Rare Complication of Biliary Stent Placement

Introduction: Formation of pseudoaneurysm is a rare but serious adverse event of biliary stenting. We present a case of a patient who presented with massive upper gastrointestinal bleeding two months after biliary stent insertion. Angiography revealed a right hepatic artery pseudoaneurysm which was successfully treated with transcatheter arterial embolization. Because bleeding may be fatal, timely diagnosis of the condition is important. Case Description/Methods: A 65-year-old-man with a past medical history of recurrent gallstone pancreatitis underwent Endoscopic Retrograde Cholangio-Pancreatography (ERCP) with sphincterotomy and fully covered metal stent placement was admitted to our hospital for severe hematemesis. Labs revealed a drop in hemoglobin from 7.6 to 5.8. After endotracheal intubation, activation of the massive transfusion protocol (MTP) Minnesota tube placement, emergent esophagogastroduodenoscopy (EGD) was performed at the bedside, which showed a large amount of clotted blood but no active bleed. The next day, again he developed severe upper gastrointestinal bleeding leading to hypovolemic shock. MTP was activated again, and a Minnesota tube reinserted. After intensive resuscitation, a computed tomography angiography (CTA) was performed which showed a 6 cm large bilobed pseudoaneurysm in the porta hepatis appears to be arising from the hepatic artery. Successful embolization of the common hepatic artery was performed without complications. No recurrent bleeding occurred over the following days. Discussion: This case demonstrates a rare complication of biliary stents which was successfully treated with transcatheter arterial embolization. It is important to consider that a pseudoaneurysm is a potential adverse event caused by a biliary stent because timely diagnosis and treatment are required to prevent fatal hemorrhage and death.Figure 1.: A. Large bilobed pseudoaneurysm in the porta hepatis appears to be arising from the hepatic artery and abuts the distal gastric antrum/proximal duodenum. B. Injection from celiac artery demonstrating a bilobed pseudoaneurysm originating from the common hepatic artery/proximal right hepatic artery at the level of the intersection with the biliary stent. C. Post IR embolization CTA showing common hepatic artery without opacification and previously seen pseudoaneurysm.

S1493 A Benign Common Bile Duct Tumor: A Diagnostic Dilemma

Introduction: Benign extrahepatic bile duct tumors are uncommon, accounting for 6% of all extrahepatic bile duct masses. They tend to occur later in life and can present early with obstructive jaundice. They are morphologically and histologically similar with each other which makes it challenging to make an accurate diagnosis. These lesions can progress to malignancy so timely diagnosis and appropriate treatment is critical. We present a case of a benign common bile duct (CBD) tumor presenting in a healthy young man that had both features of a papillary and a tubulo-villous neoplasia, causing a diagnostic dilemma. Case Description/Methods: Patient is a 48-year-old man with history of pancreatic DB-IPMN, presenting with a one-month history of post-prandial upper abdominal pain. Physical exam was unremarkable. Labs showed elevated liver enzymes with ALT, AST, and ALP of 186, 78 U/L, 537 U/L, respectively; total bilirubin was 1 mg/dL. Abdominal MRI showed diffuse dilation of intrahepatic and extrahepatic ducts, as well as dilation of the pancreas duct with a prominent ampulla. ERCP showed a bulging ampulla with abnormal appearing tissue in the distal CBD [Figure 1]. Biopsy of the of distal CBD revealed intra-papillary neoplasm of bile duct (IPNB) without features of high-grade dysplasia [Figure 2A]. A fully covered metal stent was placed with immediate improvement in symptoms and laboratory markers. Case reviewed in tumor board which recommended obtaining more tissue prior to definitive management. A repeat ERCP with SpyGlass cholangioscopy-directed biopsies and biopsies of the ampulla revealed tubule-villous adenoma with high grade dysplasia [Figure 2B]. The patient underwent curative pancreaticoduodenectomy. Final histology did not reveal invasive cancer. Discussion: IPNB is an uncommon benign extra-hepatic bile duct tumor, characterized by papillary or villous growth within the bile duct lumen. It is more common in elderly men and can progress from atypia to invasive cholangiocarcinoma. About half of IPNBs show stromal invasion at the time of surgical resection. Accurate and timely diagnosis before metastasis is critical as surgical resection has excellent outcome with 5-year tumor free survival being 80%. Our case highlights an IPNB of the distal CBD extending into the ampulla, masquerading as a more common adenoma of the duodenal ampulla.Figure 1.: ERCP showing prominent ampulla (1a) and biliary sphincterotomy (1b)Figure 2.: Figure 2A: (Biospy#1) Intraductal papillary Neoplasia (papillary proliferation of biliary epithelium along with delicate fibrovascular cores) Figure 2B: (Biospy#2) (a) At low power (40x) demonstrating tubulovillous adenoma with papillary features. Figure 2B: (Biospy#2) (b) At high power (400x) showing an area with high grade dysplasia with cribriforming, nuclear atypia, and abundant mitotic figures.

S1585 A Rare Imitator: A Case of Painless Jaundice From Neuroendocrine Carcinoma Causing Obstruction of the Common Bile Duct

Introduction: Neuroendocrine tumors (NETs) are a rare and heterogenous group of tumors with variable presentation, location, and behavior ranging from low-grade indolent tumors to high-grade aggressive carcinomas. NETs makeup about 0.5% of new malignancies and have been described in a body-wide distribution, with the gastrointestinal (GI) tract as the most common primary site. Here we describe a patient presented with painless jaundice and, after an initial misdiagnosis, was found to have an obstructive neuroendocrine carcinoma. Case Description/Methods: An 82 year-old-female presented for second opinion of a suspected cholangiocarcinoma. She had presented with weight loss and painless jaundice. Outside CT showed intrahepatic bile duct (IHD) and common bile duct (CBD) dilatation, along with liver nodules. MRCP demonstrated dilatation of intra- and extra-hepatic bile ducts and a CBD diameter of 20mm with a distal stricture suspicious for a mass. Labs showed elevated total bilirubin to 1.3mg/dL, alkaline phosphatase 204 U/L and CEA 3.5ng/mL. On evaluation with a duodenoscope, a previously placed plastic stent appeared occluded and was removed. The bile duct was cannulated with a sphincterotomy over a .025” guidewire. Cholangiogram showed a severe stricture in the distal bile duct, measuring 2 cm in length with proximal dilatation (Figure 1a). The stricture was dilated using a balloon dilator. The digital single-operator cholangioscope was advanced over the guidewire. The left and right IHDs appeared normal. The distal CBD stricture was visualized with irregular vessels concerning for primary biliary malignancy (Figure 1b). Biopsies were obtained under direct visualization using a large-caliber forceps. A 10mm x 60mm fully covered metal stent was placed into the CBD traversing the stricture (Figure 1c). The patient was discharged home the same day. Pathology showed stains positive for Synaptophysin and Chromogranin consistent with high-grade neuroendocrine carcinoma. The patient was referred to oncology to start chemotherapy. Discussion: Neuroendocrine carcinoma of the bile ducts is extremely rare and can mimic cholangiocarcinoma as it is difficult to distinguish. In previous analyses, neuroendocrine carcinomas have poor survival, with one study reporting a 10-year survival rate of 0%. This case highlights the utility of direct biopsy via cholangioscopy and the importance of early accurate identification of these tumors given their aggressive nature.Figure 1.: Evaluation and diagnosis of common bile duct obstruction. (a) Cholangiogram demonstrating severe stricture in the distal bile duct (black arrow). (b) Common bile duct stricture concerning for primary biliary malignancy. (c) Confirmation of successful placement of stent.

672 OESOPHAGOGASTRIC ANASTOMOTIC LEAK IN THE THORAX TREATED WITH COVERED METAL STENTS: SAFE AND HIGHLY SUCCESSFUL

Abstract Anastomotic leak (AL) develops in 5–22% of cases following oesophagectomy, and results in additional morbidity, and reduction in overall survival. The management of AL has evolved significantly with advances in endoscopic therapies. Covered cylindrical metal stents have been increasingly used, and insertion techniques have improved over time. We aimed to investigate the effectiveness and safety of modern metal stents in the management of AL. Methods All patients who underwent oesophagectomy with thoracic anastomosis between 2006–2020, and subsequently developed AL were retrospectively identified. Initially, treatment details and patient outcomes were assessed for the subgroup of patients where the AL was initially managed using a stent. In all cases, these were cylindrical covered metal stents. Those patients that progressed to surgery after treatment with a stent were then excluded, with the remainder compared to the subgroup of patients that underwent conservative (i.e., non-interventional) treatment for AL. Results Of 63 patients with AL, primary management was with stents in 32 (57%). Technical success was achieved in all stenting procedures, although three patients (9%) developed complications (stent migration). After stenting, six cases (19%) subsequently required escalation to operative management (thoracotomy). The remainder (N = 23) were then compared to those managed conservatively (N = 26) and were found to have a significantly longer length of hospital stay (median: 37 vs. 20 days, p = 0.003). The AL healing rate was 96% in both groups (p = 1.000); one conservatively managed patient died before healing, and one stented patient refused further treatment. Conclusion Endoscopic treatment of oesophageal AL with cylindrical covered metal stents is safe, with a high technical success rate, and low rates of stent-related morbidity. Treatment with stents also avoids the need for operative management including oesophageal disconnection in the majority of cases, whilst leading to successful healing of the AL. However, treatment with stents does significantly increase hospital stay over conservative management, particularly where multiple procedures are required.

Radiofrequency ablation of hyperplasia at an uncovered portion of a partially covered metal stent in endoscopic ultrasound-guided hepaticogastrostomy (with video).

Highlight Endoscopic ultrasound-guided hepaticogastrostomy with a partially covered metal stent has a potential risk of stent occlusion due to hyperplasia at an uncovered portion of the stent. Matsubara and colleagues report that radiofrequency ablation of hyperplasia with additional placement of an uncovered metal stent is useful for preventing recurrent stent occlusion.

EUS-guided antegrade metal stent deployment using a novel fully covered metal stent with a fine gauge stent delivery system (with video).

EUS-guided antegrade metal stent deployment using a novel fully covered metal stent with a fine gauge stent delivery system (with video).

Novel Uses of Lumen-apposing Metal Stents: A Review of the Literature.

The field of therapeutic endoscopy has seen many recent advancements. One such emerging field is the use of lumen-apposing metal stents (LAMS). Although a few LAMS have been developed, the most commonly reviewed and the only Food and Drug Administration (FDA)-approved LAMS is the Axios stent by Boston Scientific. In 2013, LAMS were initially approved by the FDA for the management of pancreatic fluid collection drainage in the presence walled-off necrosis. Pancreatic fluid collections are traditionally drained with either a plastic stent or a covered biliary self-expanding metal stent. Plastic stents have a double pigtail feature which prevents stent migration. However, their narrow lumen poses limitations as it can lead to early stent occlusion. Fully covered metal stents have larger diameters, allowing improved drainage and decreased stent occlusion but their tubular shape is prone to migration. Consequently, this results in leakage, and frequent retrievals. Over the years, due to their versatility, LAMS now have many off label uses. This includes management of gastric outlet obstruction, superior mesenteric artery syndrome, strictures, gallbladder drainage, and postsurgical collection drainage. In this review, we will be discussing the FDA approved and the nonapproved uses of LAMS.

ID: 3527114 COMBINED ENDOSCOPIC/PERCUTANEOUS RENDEZVOUS FOR BILIARY CONTINUITY… CERB THE LEAK WHEN TRADITIONAL METHODS FAIL

CBD transection or partial resection is a severe iatrogenic injury that requires surgical reconstruction and exploration. Herein, we have reported a novel combined PTC and endoscopic rendezvous technique to achieve biliary continuity in these patients. A 65-year-old female presented with abdominal pain to an outside facility a few days after elective cholecystectomy performed for symptomatic cholelithiasis. She was found to have elevated troponin levels consistent with a non-ST elevation myocardial infarction and a CT scan showed free peritoneal fluid concerning for bile leak. She was transferred to our facility for higher level of care. A HIDA scan confirmed the bile leak. An ERCP was performed with successful cannulation of the CBD, revealing a stricture in the CBD at the site of surgical clip with free upstream contrast extravasation and no communication to proximal ducts suggesting CBD disruption/resection. The case was discussed at our weekly pancreatico-biliary multispecialty conference, and due to high surgical risk resulting from her myocardial infarction and extensive regional wall motion abnormalities on transthoracic echocardiogram, a rendezvous procedure was planned after literature review of a similar case previously reported. A percutaneous trans-hepatic cholangiogram showed no passage of contrast to the CBD; a guidewire was advanced through the right intrahepatic ducts across the bifurcation. A simultaneous ERCP was performed with CBD cannulation and spy glass examination. A miniature forceps was used to grasp the guidewire proximal to the common bile duct and pulled through the scope to achieve continuous access of the patient’s intrahepatic and extrahepatic biliary tree. A covered metal stent was placed over the guidewire through the endoscope and deployed from the intrahepatic biliary tree through the extrahepatic biliary tree and into the duodenum with visible drainage of bile. A retrograde cholangiogram revealed biliary continuity with adequate opacification of the left and right biliary tree with no contrast extravasation. The patient tolerated the procedure well, with resolution of abdominal pain and neutrophilia. A follow up CT scan revealed marked improvement in the abdominal fluid collection. A combined PTC and endoscopic rendezvous technique can successfully achieve biliary continuity in patients with iatrogenic transection or partial resection of bile duct when traditional endoscopic methods fail for patients who are less than ideal candidates for surgical exploration.

Author commentary on Woo Hyun Paik et al.

Woo Hyun Paik et al. Efficacy of an internal anchoring plastic stent to prevent migration of a fully covered metal stent in malignant distal biliary strictures: a randomized controlled study

Successful biliary stone removal after resolution of post-endoscopic sphincterotomy papillary stenosis using temporary covered metal stent placement.

Successful biliary stone removal after resolution of post-endoscopic sphincterotomy papillary stenosis using temporary covered metal stent placement.

Treatment of refractory benign gastroenteral strictures with fully covered metal stents.

Video 1Treatment of refractory benign gastroenteral strictures with fully covered metal stents.

A novel laser-cut fully covered metal stent with anti-reflux valve in patients with malignant distal biliary obstruction refractory to conventional covered metal stent.

Stenting against recurrent biliary obstruction (RBO) after placement of covered metal stent (CMS) for distal malignant biliary obstruction (MBO) is still challenging. This study investigated the feasibility of a novel laser-cut fully CMS with anti-reflux valve in patients with distal MBO refractory to conventional CMS. Patients who underwent Duckbill-type metal stent (DMS) placement between June 2019 and May 2020 were included. Early complications, causes of RBO including non-occlusion cholangitis, and time to RBO (TRBO) were evaluated. TRBO of DMS was also compared with that of previous CMS. Thirty patients were included: pancreatic cancer/metastatic lymph nodes in 29 patients/one patient; duodenal stenosis in 13 patients. Technical and functional success were achieved in all patients. Mild cholangitis and mild pancreatitis developed in each one. Median follow-up period was 167days (range, 23-527days). RBO occurred in nine patients (30%): sludge formation in four patients, hemobilia in one patient, symptomatic distal stent migration in three patients, and non-occlusion cholangitis in one patient. TRBO of DMS was significantly longer than that of previous CMS (median 224days vs median 120days, P=.0025). DMS was successfully removed in all of six patients when re-intervention was needed. Duckbill-type metal stent might be safe and effective in patients with distal MBO refractory to conventional CMS.

Application of endoscopic technique in completely occluded anastomosis with anastomotic separation after radical resection of colon cancer: a case report and literature review

BackgroundAnastomosis-related complications are common after the radical resection of colon cancer. Among such complications, severe stenosis or completely occluded anastomosis (COA) are uncommon in clinical practice, and the separation of the anastomosis is even rarer. For such difficult problems as COA or anastomotic separation, clinicians tend to adopt surgical interventions, and few clinicians try to solve them through endoscopic operations.Case presentationIn this article, we present a case of endoscopic treatment of anastomotic closure and separation after radical resection for sigmoid carcinoma. After imaging examination and endoscopic evaluation, we found that the patient had a COA accompanied by a 3–4 cm anastomotic separation. With the aid of fluoroscopy, we attempted to use the titanium clip marker as a guide to perform an endoscopic incision and successfully achieved recanalization. We used a self-expanding covered metal stent to bridge the intestinal canal to resolve the anastomotic separation. Finally, the patient underwent ileostomy takedown, and the postoperative recovery was smooth. The follow-up evaluation results showed that the anastomotic stoma was unobstructed.ConclusionsWe reported the successful application of endoscopic technique in a rare case of COA and separation after colon cancer surgery, which is worth exploring and verifying through more clinical studies in the future.

Comparison of clinical outcomes of multiple plastic stents and covered metal stent in refractory pancreatic ductal strictures in chronic pancreatitis- a systematic review and meta-analysis

BackgroundSymptomatic pancreatic duct (PD) strictures in chronic pancreatitis refractory to single plastic stenting are usually managed by placement of multiple plastic stents (MPS). Fully covered self-expanding metallic stents (FCSEMS) have also been used in the management of these patients. However, the overall efficacy and safety of different types of stents is unclear from the currently available studies. We performed this meta-analysis to assess the efficacy and complications from MPS and FCSEMS in patients with PD strictures refractory to treatment with single plastic stents. MethodsSeveral electronic databases were searched for all the studies evaluating the outcome of placement of multiple plastic stents and fully covered metal stents in patients with PD strictures refractory to single plastic stenting. We calculated the Weighted Pooled Ratio (WPR) with Confidence Interval (CI) between the MPS and FCSEMS. ResultsA total of 13 studies (including 2 abstracts) were included in the analysis. MPS were placed in 106 patients and FCSEMS in 192 patients. Improvement in pain after stenting (P = 0.794), risk of recurrence of pain after removal of stent (P = 0.48) and stricture recurrence after stent removal (P = 0.52) were comparable between MPS and FCSEMS. Risk of endoscopic re-intervention was also comparable between metal stents and MPS. However, FCSEMS was associated with overall higher risk of adverse events (P < 0.0001). ConclusionFCSEMS are comparable to multiple plastic stents in the treatment of symptomatic refractory PD strictures. However, use of FCSEMS is associated with increased risk of adverse events.

EUS-guided cholecystoduodenostomy using novel dumbbell-shaped fully covered metal stent (with video).

Highlight Atalla and colleagues present a novel dumbbell-shaped fully covered self-expandable metal stent which, with its anti-migration property and relatively lower cost, is a feasible and cost-effective option as an alternative to lumen-apposing metal stents for endoscopic ultrasound-guided transduodenal gallbladder drainage for acute cholecystitis in patients who are ineligible for surgery.

Endoscopic management of chronic pancreatitis.

Chronic pancreatitis (CP) is an inflammatory process characterized by irreversible morphological changes in the pancreas. Pain is the predominant symptom observed during the course of CP. The etiopathogenesis of pain in CP is multifactorial and includes ductal hypertension due to obstruction of the pancreatic duct (PD), neuropathic causes, and extrapancreatic complications of CP like pseudocyst and distal biliary obstruction. A sizeable proportion of patients with CP are amenable to endoscopic treatment. The mainstay of endotherapy includes decompression of PD with one or more plastic stents in those with stricture, and fragmentation of PD calculi using extracorporeal shock wave lithotripsy. Nearly two-thirds of the patients achieve pain relief in the long term with endotherapy. Upfront assessment for the suitability of endotherapy is paramount to achieve the best outcomes. The predictors of poor response to endotherapy include multifocal disease, like those with multifocal strictures or multiple calculi throughout the pancreas, or a combination of both PD strictures and stones. With the emerging use of covered metal stents, the outcomes are likely to improve in cases with refractory PD strictures as well as CP-related distal biliary obstruction. The optimum stent design and indwell time of metal stents in cases with refractory PD strictures need further evaluation. Endoscopic ultrasonography has emerged as a complementary endoscopic modality in the management of CP as well as associated complications like pseudocysts, refractory pain, and vascular complications.

Technical tips and recent development of endoscopic ultrasound‐guided choledochoduodenostomy

Various efforts to improve technical success rates and decrease adverse event rates have also been described in endoscopic ultrasound (EUS)‐guided choledochoduodenostomy (CDS). In particular, lumen‐apposing metal stents (LAMS) may open novel opportunities in EUS‐biliary drainage (BD). To date, various studies have been reported with EUS‐CDS using LAMS, so we should clarify the benefits and limitations of recent EUS‐CDS based on developments in both techniques and devices. In this review, we provide technical tips and describe recent developments in EUS‐CDS, along with a review of the recent literature (between 2015 and 2020). The overall technical success rate is 95.0% (939/988), and the overall clinical success rate is 97.0% (820/845). The most frequent adverse event is cholangitis or cholecystitis (24.5%, 27/110). According to previous review, pneumoperitoneum (28%, 9/34) or peritonitis associated with bile leak (23.5%, 8/34) was most commonly observed. This difference might be based on improvements in dilation devices or the use of covered metal stents. Several randomized controlled trials comparing EUS‐CDS and endoscopic retrograde cholangiopancreatography (ERCP) for malignant biliary obstruction have recently been reported. To summarize, overall technical success rates for ERCP and EUS‐CDS were 92.7% (101/109) and 91.1% (72/79), respectively (p = 0.788). Overall clinical success rates for ERCP and EUS‐CDS were 94.1% (96/102) and 93.6% (72/78), respectively (p = 0.765). Further high‐quality evidence is needed to establish EUS‐CDS as a primary drainage technique.

Comparison of a covered metallic ureteral stent and a double-J stent for malignant ureteral obstruction in advanced gastric cancer

To compare the patency and safety of covered metallic stents (CMS) and the double-J stent (DJS) for treating malignant ureteral obstruction (MUO) in advanced gastric cancer (AGC). Between 2016 and 2018, the medical records of 61 patients (84 ureters; CMS, 39 patients, 54 ureters; DJS, 22 patients, 30 ureters) with MUO caused by AGC were reviewed retrospectively. The Kaplan-Meier method and log-rank test were used to evaluate differences of primary or assisted primary patency between groups. Cox regression was conducted separately for early (within 7 days) and late (after 7 days) primary patency. Technical success of CMS placement was 100% (54/54) and 96.8% (29/30) for DJS (p=0.357). The cumulative stent patency rates at 1, 3, 6, and 12 months were 77%, 74%, 70%, and 70%, in the CMS group and 72%, 60%, 53%, and 26%, in the DJS group. Apart from the period within 7 days (p=0.784), primary patency was consistently higher in the CMS group when compared to the DJS group over the entire follow-up period (p=0.034). Assisted primary patency was consistently higher in the CMS group than in the DJS group over the entire follow-up period (p=0.001). The CMS group was more likely to have complications than the DJS group (48.1% versus 16.7%, p=0.004). Complications were minor, self-limiting events such as haematuria/haematoma. CMS had better late patency and assisted primary patency than DJS. Procedure-related minor complications more frequently occurred with CMS.

EUS-guided hepaticogastrostomy for management of cholangitis, hepatolithiasis, and anastomotic stricture after Roux-en-Y hepaticojejunostomy.

Video 1EUS-guided hepaticogastrostomy for management of cholangitis, hepatolithiasis, and anastomotic stricture after Roux-en-Y hepaticojejunostomy.

Clinical evaluation of physician-controlled guidewire manipulation during endoscopic ultrasound-guided hepaticogastrostomy (with video).

Background and study aims Endoscopic ultrasound (EUS)-guided hepaticogastrostomy (HGS) may be most complex because of the EUS-guided biliary drainage procedure and variations in the course of the intrahepatic bile duct compared with the common bile duct (CBD). Appropriate guidewire insertion is essential. Physician-controlled guidewire manipulation (PCGW) might improve technical success rates of bile duct cannulation. The present study aimed to determine the technical feasibility and safety of PCGW during EUS-HGS. Patients and methods A total of 122 consecutive patients who were scheduled to undergo EUS-HGS between October 2017 and April 2019 were prospectively registered. The primary endpoint was the technical success rate of guidewire insertion into the CBD or hepatic hilum. Guidewire insertion was considered to have failed if the HGS assistant failed to achieve manipulation. Results The intrahepatic bile duct was successfully punctured in 120 of 122 patients. During guidewire insertion by the HGS assistant, guidewire fracture was observed in one patient. The guidewire was successfully inserted into the biliary tract and manipulated by the HGS assistant in 96 patients. PCGW was thus attempted for the remaining 23 patients. The guidewire was inserted by PCGW in all 23 patients, improving the technical success rate for guidewire insertion from 80 % to 100 %. After tract dilation, we deployed covered metal stents and plastic stents in 117 and two patients, respectively. The overall technical success rate for EUS-HGS was 97.5 % (119/122). Adverse events comprising bile peritonitis or leakage developed in five patients. Conclusion PCGW might contribute to improving the success rate of EUS-HGS.