Deployment Of Self-expandable Metal Stents Research Articles

Efficacy of pancreatic duct stenting to prevent postendoscopic retrograde cholangiopancreatography pancreatitis after covered self-expandable metal stentdeployment.

Although covered self-expandable metal stents (CSEMSs) are associated with the risk of postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis due to pancreatic duct (PD) orifice obstruction, they are often used for biliary drainage treatment in malignant biliary obstruction (MBO). This study aimed to investigate the efficacy of PD stenting in preventing post-ERCP pancreatitis after CSEMS implantation. This retrospective cohort study analyzed 554 patients with transpapillary CSEMS for MBO. Patients with noninitial deployment, benign disease, CSEMS deployment above the papilla, surgically altered anatomy, uncovered self-expandable metal stents, multiple thin self-expandable metal stents, and unavailable procedure videos were excluded. Logistic regression analysis estimated the association between PD stenting and post-ERCP pancreatitis incidence. We adjusted for age, sex, pancreatitis history, prophylactic rectal nonsteroidal anti-inflammatory drug use, naïve papilla, MBO etiology, and prolonged biliary cannulation time. Among 554 patients, 67 (12.1%) experienced post-ERCP pancreatitis. Post-ERCP pancreatitis was recorded in 13.7% of patients in the non-PD stenting and 4.3% in the PD stenting groups. Pancreatic duct stenting was associated with lower risks of post-ERCP pancreatitis (odds ratio [OR] 0.28; 95% confidence interval [CI] 0.099-0.79; P = 0.028). In multivariable analysis, the association between PD stenting and lower post-ERCP pancreatitis incidence was consistent (OR 0.19; 95% CI 0.062-0.58; P = 0.0034). Pancreatic duct stenting could reduce the risk of post-ERCP pancreatitis after CSEMSs.

Endoscopic four-branched stent-in-stent deployment of self-expandable metal stents in malignant hilar biliary obstruction.

Endoscopic four-branched stent-in-stent deployment of self-expandable metal stents in malignant hilar biliary obstruction.

Pilot Study of Dumbbell-Type Covered Self-Expandable Metal Stent Deployment for Benign Pancreatic Duct Stricture (with Videos)

BackgroundFully-covered, self-expandable metal stents (FCSEMS) have been deployed to treat symptomatic chronic pancreatitis (CP) complicated with main pancreatic duct (MPD) stricture. Although this strategy can be effective, it has the disadvantages of stent migration or stent-induced ductal change. Removal of an FCSEMS can also be challenging in the face of distal migration because of MPD stricture. Dumbbell-type FCSEMS have been developed to prevent stent-induced ductal changes and improve removability when treating benign biliary stricture. This stent might also confer clinical benefits upon patients with MPD stricture. AimsThe present pilot study aimed to determine the feasibility and safety of deploying dumbbell-type FCSEMS in patients with CP complicated by MPD stricture. MethodStents were deployed in 22 patients with MPD stricture caused by CP and complicated by abdominal pain. ResultsStrictures were located at the head (n = 19), body (n = 2), and head and tail (n = 1) of the MPD. Stents were deployed above the papilla in three patients. All stents were deployed for a median duration of 142 (range, 49–190) days and removed. The resolution of MPD strictures was confirmed by pancreatography in 19 (86.3%) patients. Two metal stents that spontaneously tore during removal from two patients had otherwise functioned normally. Only three patients developed recurrent MPD stricture during a median follow-up of 419 (range, 261–484) days.. ConclusionsDeployment of a dumbbell-type FCSEMS seems feasible for MPD stricture, and the rate of adverse events is acceptable.

Recent advancements in stent therapy in patients with malignant gastroduodenal outlet obstruction.

Gastric outlet obstruction (GOO) is one of severe comorbidities caused by many kinds of malignant diseases and is associated with not only degradation of patients' quality of life but also mortality. Although surgical bypass is one of the main therapies for malignant GOO, it is often difficult to perform in end-stage patients. The deployment of self-expandable metallic stents (SEMSs) has recently become a viable alternative to surgical bypass for malignant GOO. This technique is less invasive and more effective, particularly in patients with poor prognoses. Many reports have referred to the feasibility, effectiveness, and safety of the placement of SEMSs for malignant GOO. According to these reports, the rates of technical and clinical success were reported to be relatively high and the rate of adverse events to be acceptable. However, precautions against severe adverse events such as massive bleeding and perforation are necessary. Several reports have described the differences in clinical results among different kinds of SEMSs. The presence of a covered design for SEMSs may affect the patency of SEMSs and the rate of stent dysfunction. Selection of the SEMS according to axial force may affect successful achievement of long patency of SEMSs and avoidance of gastroduodenal perforation at the bending site of the duodenum. Compared with high technical success rates nearing 100%, clinical success rates were usually lower than technical success. Therefore, determination of predictive factors for failure of clinical success is important. Several papers reported that low performance status could be associated with failure of clinical success. However, the association of clinical success with other factors such as carcinomatosa and ascites remains controversial, which is a problem to be solved. Reintervention with SEMS using the stent-in-stent method after stent dysfunction can be performed effectively as well as placement of the first SEMS.

A multicenter experience of through-the-scope balloon-assisted enteroscopy in surgically altered gastrointestinal anatomy.

Surgically altered gastrointestinal anatomy poses challenges for deep enteroscopy. Current overtube-assisted methods have long procedure times and utilize endoscopes with smaller working channels that preclude use of standard accessories. A through-the-scope balloon-assisted enteroscopy (TTS-BAE) device uses standard endoscopes with a large working channel to allow metallic and plastic stent insertion. We aim to determine the efficacy and safety of TTS-BAE in patients with altered surgical anatomy. A retrospective, multicenter study of TTS-BAE in altered anatomy patients at two USA and one German institution was performed between January 2013 and December 2014. Type of anatomy, procedure indication and duration, adverse events, and target, technical, and clinical success were recorded. A total of 32 patients (mean age 54years, Caucasian 81.6%, female 42.1%, mean BMI 25.4kg/m2) underwent 38 TTS-BAE procedures. Thirty-two percent of cases had a prior attempt at conventional enteroscopy which failed to reach the target site. The target was successfully reached in 23 (60.5%) cases. Of the 23 cases that reached the intended target, 22 (95.7%) achieved technical success and 21 (91.3%) achieved clinical success. The median procedure time was 43min. Target, technical, and clinical success rates for TTS-BAE-assisted ERCP (n=31) were 58.1, 54.8 and 54.8%. Seven self-expandable metallic stents (five biliary, two jejunal) were attempted, and all successfully deployed. Adverse events occurred in 4 (10.4%) cases, including one luminal perforation. TTS-BAE is an alternative to overtube-assisted enteroscopy that is comparable in safety in patients with surgically altered anatomies. Technical success in the instances where the target had been reached was excellent. TTS-BAE confers an advantage over overtube-assisted enteroscopy as it can facilitate the deployment of self-expandable metallic stents in the biliary tree and deep small bowel.

Self-Expandable Metal Stents in Esophageal Cancer in a High HIV Prevalence Area: A Survival Analysis and Evaluation of Prediction Scores.

Esophageal cancer (EC) and human immunodeficiency virus (HIV) are common in parts of South Africa. Squamous cell carcinoma of the esophagus in KwaZulu-Natal, South Africa presents generally in advanced stages and is mostly palliated by the deployment of self-expandable metal stent (SEMS). This study analyses these relationships between coexistent HIV infection, SEMS deployment, and survival scores. Information on patients managed with SEMS between October 2013 and December 2014 was retrieved from a prospective database of EC and followed up until April 2015. Data collected included demographics, HIV status, clinical presentation, prognostic indicators, management, and survival. Prognostic factors were calculated in relation to outcome. One hundred five patients with EC had median ages of 61 (SD±11.4) and median body mass index of 17.45. Squamous cell carcinoma of the esophagus was diagnosed in 90 patients and adenocancer in 7 patients. Tumors were located in the proximal (10), middle (64), and distal (29) esophagus. Stage IV EC had a significant shorter survival of fewer than 3 months compared with stage III cancer (P=0.009). A C-reactive protein >150 mg/L was 3.6 times more likely to predict survival of fewer than 3 months than a value <50 mg/L (P=0.035). A proximal stent position significantly predicted shorter survival (P=0.035). The Steyerberg prognostic score proved ineffective in predicting survival of <3 months in our setting. Of the 84 patients tested for HIV, 23 were positive. Thirteen patients were on highly active antiretroviral therapy surviving significantly longer than those without this medication (P=0.036). Stage IV cancer and C-reactive protein >150 predicted survival of <3 months significantly better than the Steyerberg prediction score or other markers. Highly active anti-retroviral therapy had a positive impact on survival; however, SEMS placement in the proximal esophagus was associated with shorter survival.

Hepaticogastrostomy or choledochoduodenostomy for distal malignant biliary obstruction after failed ERCP: Is there any difference?

EUS-guided biliary drainage (BD) is an evolving alternative technique for patients with malignant biliary obstruction for which ERCP failed. To compare the outcomes of 2 nonanatomic EUS-guided BD routes: hepaticogastrostomy (HPG) and choledochoduodenostomy (CD). Prospective, randomized trial. Tertiary endoscopic referral center. Forty-nine patients with unresectable distal malignant biliary obstruction and failed ERCP were included. The HPG group had 25 patients and the CD group had 24 patients. EUS-guided HPG or CD. In all procedures, a biliary puncture with a 19-gauge needle followed by cholangiography, wire advancement, track dilation, and self-expandable metal stent deployment were performed. Technical and clinical success, quality of life, adverse events, and survival. The technical success rate was 96% for HPG and 91% for CD. The clinical success rate was 91% for HPG and 77% for CD. The mean procedural time was 47.8 minutes for HPG and 48.8 minutes for CD. The mean scores of quality of life were similar during follow-up. The overall adverse event rate was 16.3% (20% for the HPG group and 12.5% for the CD group). One patient with a bile leak required percutaneous biloma drainage. There was no statistical difference between the 2 techniques and no difference with regard to survival time between the 2groups. Single-center study. HPG and CD techniques are similar in efficacy and safety. Both HPG and CD seem valid alternativeoptions for BD in patients with distal malignant biliary obstruction after failed ERCP.

Self-Expanding Metal Stent (SEMS): an innovative rescue therapy for refractory acute variceal bleeding.

Background: Acute variceal bleeding (AVB) is a life-threatening complication of liver cirrhosis or less commonly splenic vein thrombosis. Pharmacological and endoscopic interventions are cornerstones in the management of variceal bleeding but may fail in 10 – 15 % of patients. Rescue therapy with balloon tamponade (BT) or transjugular intrahepatic portosystemic shunt (TIPS) may be required to control refractory acute variceal bleeding effectively but with some limitations. The self-expanding metal stent (SEMS) is a covered, removable tool that can be deployed in the lower esophagus under endoscopic guidance as a rescue therapy to achieve hemostasis for refractory AVB. Aims: To evaluate the technical feasibility, efficacy, and safety of SEMS as a rescue therapy for AVB. Methods: In this review article, we have performed an extensive literature search summarizing case reports and case series describing SEMS as a rescue therapy for AVB. Indications, features, technique, deployment, success rate, limitations, and complications are discussed. Results: At present, 103 cases have been described in the literature. Studies have reported 97.08 % technical success rates in deployment of SEMS. Most of the stents were intact for 4 – 14 days with no major complications reported. Stent extraction had a success rate of 100 %. Successful hemostasis was achieved in 96 % of cases with only 3.12 % found to have rebleeding after placement of SEMS. Stent migration, which was the most common complication, was observed in 21 % of patients. Conclusion: SEMS is a safe and effective alternative approach as a rescue therapy for refractory AVB.

Covered self-expandable metal stent deployment promise safe neoadjubant chemotherapy in patients with borderline resectable pancreatic head cancer

Covered self-expandable metal stent deployment promise safe neoadjubant chemotherapy in patients with borderline resectable pancreatic head cancer

Laparoscopic Deployment of Biliary Self-Expandable Metal Stent (SEMS) for One-Step Palliation in 23 Patients with Advanced Pancreatico-Biliary Tumors—a Pilot Trial

BackgroundExploratory laparoscopy is commonly undertaken in patients with highly suspicious biliary and pancreatic lesions to facilitate diagnosis and staging cancer is present. If an unresectable tumor is identified, a second endoscopic procedure may be required do deploy a self-expandable metal stent (SEMS) for palliation. As endoscopic retrograde cholangio pancreatography (ERCP) may be unsuccessful in up to 20% of patients, we evaluated the feasibility and safety of deployment of self-expandable metal stents at the same time as the initial laparoscopy. Patients and MethodsA total of 23 eligible patients (8 male and 15 female) with malignant obstruction of the common bile duct underwent deployment of SEMS at laparoscopy. Primary outcome measure was the successful laparoscopic deployment of stent and secondary outcome measure was complications rates. ResultsIndications for stent deployment were unresectable pancreatic cancer in 18, cholangiocarcinoma in two, neuroendocrine tumor in one and ampullary adenocarcinoma in two patients. The median age was 73 years (range 49–93). Twenty-two of 23 stents were deployed successfully: 17 stents were deployed transcystically and five via a choledochotomy. Median times for laparoscopic exploration and SEMS deployment were 165 min (range 105–230) and 20 min (range 10–50), respectively. Pre- and post-procedures median total bilirubin were 9.4 mg/dl (range 5.4–17.5) and 4.0 (range 2.6–7.1). The median size of the pancreatic mass was 3 cm (range 2–5 cm) and that of the common bile duct (CBD) from 9.2mm (range 7.2–17.4). The mean duration of laparoscopy was 170 min (range 120–230 min) and that for stent deployment 23 min (range 10–50 min). Complications included bleeding, obstruction, and wound infection. Bleeding occurred on day 7 in two patients and on day 30 in one patient; bleeding occurred at the gastrojejunal anastomosis site and was successfully treated with endoscopic hemostasis. A total of three stent obstructions were identified: one each at 60, 90, and 120 days follow-up. All complications were successfully managed endoscopically. There were a total of seven deaths, six as a result of progressive cancer and one of surgical wound infection and ensuing complications. ConclusionThis study demonstrates that laparoscopic deployment of self-expandable metal bile duct stents is feasible and safe. This option appears to be a reasonable option in patients with inoperable malignant obstruction of the distal common bile duct.

Ultraflex stents for the management of airway complications in lung transplant recipients

Respirology 2003;8:59–64. Chhajed PN, Malouf MA, Tamm M, Glanville AR. Comments: In this study, Chhajed and coworkers report their experience with the use of an uncovered Ultraflex (nitinol) stent in the management of airway stenosis in 9 lung transplant recipients. The indications for stent placement were stenosis of the large airway in 4 patients, combined stenosis and bronchomalacia in 3 patients, and tracheomalacia and bronchomalacia in 1 patient each. A total of 11 stents were deployed in 9 patients. Stents were placed using a flexible bronchoscope with fluoroscopy guidance under conscious sedation. Proximal release stents were used in 6 patients and distal release stents in 3 patients. The mean ± standard deviation increase in forced expiratory volume in 1 second (FEV1) after insertion of the procedure was 522 ± 391 mL (range, 120–1150 mL). Successful stent deployment led to improvement in dyspnea in all patients. In 2 patients, initial placement of the stent was unsatisfactory as a result of proximal displacement of the stent delivery device. This problem occurred with the proximal release stent delivery device in both cases. Stricture resulting from excessive growth of granulation tissue formed in 1 patient, and it was treated with balloon dilatation and laser resection. Stent migrated in 1 patient from its original position, and it had to be removed. No patient developed stenosis at the stent extremities or mucus plugging during the follow-up period of 263 ± 278 days after the procedure. Airway complications are common after lung transplantation. Common complications include anastomotic stenosis, bronchomalacia, or a combination of stenosis and malacia, granulation tissue, and anastomosis dehiscence. The majority of patients with symptomatic airway stenosis after lung transplantation require interventional bronchoscopic treatment (Chest 2001;120:1894–9). The choice of treatment depends on endoscopic findings. For stenosis, balloon dilatation is the first-line treatment. However, despite its high initial success, the majority of patients eventually require airway stent as a result of recurrence of stenosis or as a result of development of bronchomalacia. There is no single ideal stent for this purpose. Recent reports indicate successful deployment of self-expandable metal stents in these patients. Uncovered wall stents have been considered more suitable than prior designs of metallic stents (such as Gianturco and Palmaz stents) for this purpose. However, in a prior study, Chhajed and coworkers reported granulation tissue and mucus plugging in 27% patients each after placement of uncovered wall stents in lung transplant recipients (Chest 2001;120:1894–9). The present study by Chhajed and coworkers suggests that the Ultraflex stent could be better than uncovered wall stents for managing airway stenosis after lung transplantation as a result of the very low risk of secretion accumulation, mucus plugging, and development of granulation tissue at the ends of the stent. Although the sample size was small, the results indicate that the Ultraflex stent is presently the most useful metal stent for management of airway stenosis in lung transplant recipients.