Double-pigtail Plastic Stents Research Articles

The Role of EUS-Guided Drainage in the Management of Postoperative Fluid Collections after Pancreatobiliary Surgery

Postoperative fluid collection (POFC) is a challenging complication following pancreatobiliary surgery. Traditional treatment with surgical drainage is associated with significant morbidity, while percutaneous drainage is associated with a higher rate of recurrence and the need for repeated interventions. Studies have shown that endoscopic ultrasound (EUS)-guided drainage may offer a promising solution to this problem. There are limited data on the ideal therapeutic protocol for EUS-guided drainage of POFC including the timing for drainage; type, size, and number of stents to use; and the need for endoscopic debridement and irrigation. Current practices extrapolated from the treatment of pancreatic pseudocysts and walled-off necrosis may not be applicable to POFC. There are increasing data to suggest that drainage procedures may be performed within two weeks after surgery. While most authors advocate the use of double pigtail plastic stents (DPPSs), there have been a number of reports on the use of novel lumen-apposing metal stents (LAMSs), although no direct comparisons have been made between the two.

Stent occlusion in endoscopic ultrasound-guided gallbladder drainage from bleeding mitigated by double pigtail plastic stent deployment within lumen apposing metal stent

Stent occlusion in endoscopic ultrasound-guided gallbladder drainage from bleeding mitigated by double pigtail plastic stent deployment within lumen apposing metal stent

Lumen-apposing metal stents versus double-pigtail plastic stents in the endoscopic step-up approach for infected necrotizing pancreatitis

Lumen-apposing metal stents versus double-pigtail plastic stents in the endoscopic step-up approach for infected necrotizing pancreatitis

Head-to-head comparison between endoscopic ultrasound guided lumen apposing metal stent and plastic stents for the treatment of pancreatic fluid collections: A systematic review and meta-analysis.

Peripancreatic fluid collections (PFCs) result from acute or chronic pancreatic inflammation that suffers a rupture of its ducts. Currently, there exists three options for drainage or debridement of pancreatic pseudocysts and walled-off necrosis (WON). The traditional procedure is drainage by placing double pigtail plastic stents (DPPS); lumen-apposing metal stent (LAMS) has a biflanged design with a wide lumen that avoids occlusion with necrotic tissue, which is more common with DPPS and reduces the possibility of migration. We performed a systematic review and meta-analyses head-to-head, including only studies that compare the two main techniques to drainage of PFCs: LAMS vs DPPS. We conducted a systematic review in different databases, such as PubMed, OVID, Medline, and Cochrane Databases. This meta-analysis considers studies published from 2014 to 2020, including only studies that compare the two main techniques to drainage of PFCs: LAMS vs DPPS. Thirteen studies were included in the meta-analyses. Only one of all studies was a randomized controlled trial. These studies comprise 1584 patients; 68.2% were male, and 31.8% were female. Six hundred sixty-three patients (41.9%) were treated with LAMS, and 921 (58.1%) were treated with DPPS. Six studies included only WON in their analysis, two included only pancreatic pseudocysts, and five studies included both pancreatic pseudocysts and WON. The technical success was similar in patients treated with LAMS and DPPS (97.6% vs 97.5%, respectively, P=.986, RR=1.00 [95% CI 0.93-1.08]). The clinical success was similar in both groups (LAMS: 90.1% vs DPPS: 84.2%, P=.139, RR=1.063 [95% CI 0.98-1.15]). Patients treated with LAMS had a lower complication rate than the DPPS groups, with a significant statistical difference (LAMS: 16.0% vs DPPS: 20.2%, P=.009, RR=0.746 [95% CI 0.60-0.93]). Bleeding was the most common complication in the LAMS group (33 patients, [5.0%]), whereas infection was the most common complication in the DPPS group (56 patients, [6.1%]). The LAMS migration rate was lower than in the DPPS (0.9% vs 2.2%, respectively, P=.05). The mortality rate was similar in both groups, 0.6% in the LAMS group (four patients) and 0.4% in the DPPS group (four patients; P=.640). The PFCs drainage is an indication when persistent symptoms or PFCs-related complications exist. EUS guided drainage with LAMS has similar technical and clinical success to DPPS drainage for the management of PFCs. The technical and clinical success rates are high in both groups. However, LAMS drainage has a lower adverse events rate than DPPS drainage. More randomized controlled trials are needed to confirm the real advantage of LAMS drainage over DPPS drainage.

Double-pigtail plastic stent is effective as a rescue therapy after obstruction of choledochoduodenostomy using a lumen-apposing metal stent.

Double-pigtail plastic stent is effective as a rescue therapy after obstruction of choledochoduodenostomy using a lumen-apposing metal stent.

Indwelling double-pigtail plastic stents for treating disconnected pancreatic duct syndrome-associated peripancreatic fluid collections: long-term safety and efficacy.

Long-term transmural double-pigtail stent (DPS) placement is recommended for patients with disconnected pancreatic duct syndrome (DPDS) and peripancreatic fluid collections (peri-PFCs). The long-term safety and efficacy of indwelling DPSs were evaluated. Medical files of patients treated with DPS for DPDS-associated peri-PFC and with a follow-up ≥ 48 months were reviewed. Early ( < 30 days) and late complications of DPS placement were evaluated and the primary endpoint, i. e., incidence of late complications per 100 patient-years of follow-up, was calculated. Short- and long-term success rates of endoscopic treatment and rate of peri-PFC recurrence were among secondary endpoints. From 2002 to 2014 we identified 116 patients, with mean (SD) follow-up of 80.6 (34.4) months. Among early complications (n = 20), 6 occurred peri-interventionally. Late complications (n = 17) were mainly pain due to DPS-induced ulcer or erosion (n = 10) and 14 of these were treated conservatively or by stent removal; 2 gastro-pancreatico-colo-cutaneous fistulas and 1 persisting bleed required surgical intervention. No DPS-related deaths were recorded. The incidence rate (95 %CI) of late complications was 2.18 (1.27-3.49) per 100 patient-years of follow-up. Short- and long-term success rates (with 95 %CI) of endoscopic treatment were 97.4 % (94.5 %-100 %) and 94 % (89.6 %-98.3 %), respectively. The peri-PFC recurrence rate was 28 % (20.1 %-35.9 %), and 92.3 % of these occurred within the first 2 years. Stent migration, chronic pancreatitis, and length of stent (> 6 cm) were independently associated with higher rates of peri-PFC recurrence. Long-term transmural drainage with DPS is a safe and effective treatment for DPDS-associated peri-PFCs. However, about one quarter of peri-PFCs will recur.

Single-use duodenoscope in the management of an elderly patient with difficult bile duct stones: laser lithotripsy using a disposable cholangioscope.

Video 1Single-use duodenoscope in the management of an elderly patient with difficult bile duct stones using laser lithotripsy and a disposable cholangioscope.

Is a coaxial plastic stent within a lumen-apposing metal stent useful for the management of distal malignant biliary obstruction?

There are uncertainties concerning the possible benefits derived from the insertion of double-pigtail plastic stents (DPS) within lumen-apposing metal stents (LAMS) in EUS-guided choledochoduodenostomy (CDS). The aim of this study was to determine whether a DPS within a biliary LAMS offers a potential benefit in EUS-guided CDS for the palliative management of malignant biliary obstruction. This was a multicentre retrospective study at three tertiary institutions. May 2015 to August 2020. Two interventional strategies (LAMS alone and LAMS plus DPS) were compared. The choice was the endoscopist's discretion. Inclusion: unresectable/inoperable biliopancreatic tumours with previous failed ERCP. Clinical success: bilirubin decrease > 30% at 4weeks. Forty-one consecutive cases of EUS-CDS using biliary LAMS were treated (22 women; mean age, 72.3years) during the study period. The procedure was technically successful in 39 (95.1%), who were managed using the two strategies (22 LAMS alone; 17 LAMS plus DPS). No differences between the groups, in terms of clinical success (77.3 vs 87.5%, p = 0.67), adverse events (AEs, 13.6 vs 11.8%, p = 0.99), recurrent biliary obstruction (RBO, 13.6 vs 23.5%, p = 0.67), or survival rate (p = 0.67) were encountered. The LAMS alone group had a shorter length of procedure (50min vs 66min, p = 0.102). No risk factors related to clinical success, AEs, RBO, or survival were detected. The technical variant of adding a coaxial DPS within LAMS in EUS-CDS seems not to be enough to prevent biliary morbidities, and it is a time-consuming strategy. Although prospective studies are needed, these results do not support its routine use.

Efficacy and safety of endoscopic ultrasound-guided drainage of pancreatic pseudocysts using double-pigtail plastic stents: A single tertiary center experience

OBJECTIVES:Pancreatic pseudocysts (PPC) are fluid collections with a well-defined wall that persist for more than 4 weeks inside or around the pancreas as a result of pancreatic inflammation and/or a ductal lesion. PPC have been successfully treated with endoscopic ultrasound (EUS)-guided drainage using different stents. This study aimed to evaluate the safety and efficacy of EUS-guided drainage of PPC using double-pigtail plastic stents in a tertiary hospital.METHODS:Patients with PPC referred for EUS-guided drainage between May 2015 and December 2019 were included in this case series. The primary endpoint was to evaluate the efficacy (clinical success) and safety (adverse events and mortality) of EUS-guided drainage of PPC. Secondary endpoints included technical success and pseudocyst recurrence.RESULTS:Eleven patients (mean age, 44.5±18.98 years) were included in this study. The etiologies for PPC were acute biliary pancreatitis, chronic alcoholic pancreatitis, and blunt abdominal trauma. The mean pseudocyst size was 9.4±2.69 cm. The clinical success rate was 91% (10/11). Adverse events occurred in three of 11 patients (27%). There were no cases of mortality. The technical success rate was 100%. Pseudocyst recurrence was identified in one of 11 patients (9%) at 12 weeks after successful clinical drainage and complete pseudocyst resolution.CONCLUSION:EUS-guided transmural drainage of PPC using double-pigtail plastic stents is safe and effective with high technical and clinical success rates.

Safety and efficacy of lumen-apposing metal stents versus plastic stents to treat walled-off pancreatic necrosis: systematic review and meta-analysis.

Background and study aims Lumen-apposing metal stents (LAMS) are increasingly used for drainage of walled-off pancreatic necrosis (WON). Recent studies suggested greater adverse event (AE) rates with LAMS for WON. We conducted a systematic review and meta-analysis to compare the safety and efficacy of LAMS with double-pigtail plastic stents (DPPS) for endoscopic drainage of WON. The primary aim was to evaluate stent-related AEs. Methods In October 2019, we searched the Ovid (Embase, MEDLINE, Cochrane) and Scopus databases for studies assessing a specific LAMS or DPPS for WON drainage conducted under EUS guidance. Safety outcomes were AE rates of bleeding, stent migration, perforation, and stent occlusion. Efficacy outcomes were WON resolution and number of procedures needed to achieve resolution. A subanalysis including non-EUS-guided cases was performed. Results Thirty studies including one randomized controlled trial (total 1,524 patients) were analyzed. LAMS were associated with similar bleeding (2.5 % vs. 4.6 %, P = 0.39) and perforation risk (0.5 % vs. 1.1 %, P = 0.35) compared to DPPS. WON resolution (87.4 % vs. 87.5 %, P = 0.99), number of procedures to achieve resolution (2.09 vs. 1.88, P = 0.72), stent migration (5.9 % vs. 6.8 %, P = 0.79), and stent occlusion (3.8 % vs. 5.2 %, P = 0.78) were similar for both groups. Inclusion of non-EUS-guided cases led to significantly higher DPPS bleeding and perforation rates. Conclusions LAMS and DPPS were associated with similar rates of AEs and WON resolution when limiting analysis to EUS-guided cases. Higher bleeding rates were seen in historical studies of DPPS without EUS guidance. Additional high-quality studies of WON treatment using consistent outcome definitions are needed.

Cerrahi için yüksek riskli bir hastada akut kolesistitin endoskopik transpapiller drenajı

Akut kolesistit, safra taşlarının sık görülen komplikasyonlarından birisidir. Akut kolesistit için genellikle kolesistektomi önerilir. En sık tercih edilen yöntem laparoskopik kolesistektomidir. Ancak ameliyatın kontrendike olduğu durumlarda endoskopik transpapiller safra kesesi drenajı alternatif bir yöntem olarak kabul edilir. 86 yaşında kadın hasta, acil servise, sağ üst kadran ağrısı ve ateş yüksekliği yakınmalarıyla başvurduğunda çekilen abdomen tomografisinde taşlı kolesistit saptandı. Hasta kolesistit, kolanjit ve biliyer sepsis ön tanılarıyla yatırılarak acil endoskopik retrograd kolanjiyografi yapıldı. Safra kesesine 10 Fr 10 cm double pigtail plastik stent ve sağ ve sol ana safra kanalına uzanacak şeklide iki adet 10 Fr double pigtail stent yerleştirildi. İşlem sonrası klinik takiplerinde hasta hızlıca düzeldi ve post-operatif 1 hafta sonra taburcu edildi. Safra kesesinin endoskopik drenajı, transpapiller yoldan veya transmural yoldan endoskopik ultrasonografi ile yapılabilir. Prosedür teknik olarak başarılı olduğunda, transpapiller drenaj, akut kolesistitli hastaların %90’ından fazlasında etkili tedavi sağlar. Endoskopik drenaj yöntemleri kolesistektomi riski yüksek olan hastalarda teknik olarak uygulanabilir, güvenli ve etkili tekniklerdir.

A novel value-based scoring system for endoscopic ultrasound-guided drainage of pancreatic fluid collections: a single-centre comparative study of plastic and lumen-apposing metal stents (NOVA study)

Healthcare resources are finite. Value in healthcare can be defined as patient health outcomes achieved per monetary unit spent. Attempts have been made to quantify the value of luminal endoscopy, but there is little in the medical literature describing the value of the complex therapeutic endoscopic activity. This study aimed to characterise the value of endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs) with either plastic or lumen-apposing metal stents (LAMSs). This is a single-centre, retrospective-prospective comparative study of 39 patients, who underwent EUS-guided PFC drainage between 2009 and 2018. Procedure value was calculated using the formula Q/(T/C), where Q is the quality of procedure adjusted for complications, T procedure duration and C is the complexity adjustment. Quality and complexity were estimated on a 1-4 Likert scale based on the American Society for Gastrointestinal Endoscopy criteria. Time (in minutes) was recorded from the patient entering and leaving the procedure room. Endoscopy time calculated from procedure time was considered a surrogate marker of cost as individual components of procedure cost were not itemized. Of 39 identified patients who underwent EUS-guided PFC drainage, 11 received double pigtail plastic stents (DPPSs) and 28 received LAMSs. The two groups were comparable in age, gender and aetiology. Nearly 40% of the LAMS interventions were considered high value but only 11% of the plastic stent interventions achieved the same. The difference predominantly was due to a higher rate of complications and longer procedure time. In this single-centre study, EUS-guided PFC drainage using LAMS was found to be a higher value procedure compared to the use of DPPS.

Importance of Disconnected Pancreatic Duct Syndrome in Recurrence of Pancreatic Fluid Collections Initially Drained Using Lumen-Apposing Metal Stents

Indwelling plastic endoprosthesis in patients with disconnected pancreatic duct syndrome (DPDS) reduces the risk of pancreatic fluid collection (PFC) recurrence. Although lumen-apposing metal stents (LAMS) are used with increasing frequency for PFC drainage, they require timely removal and little is known about their effects in patients with DPDS and recurrence of PFC. We performed a prospective study of patients who underwent endoscopic ultrasound-guided drainage of PFC using LAMS and were found to have DPDS. After resolution of PFC, LAMS were replaced with double-pigtail plastic stents. The primary outcome was to compare PFC recurrence between patients with DPDS who did vs did not receive replacements with plastic stents after removal of the LAMS. Of 188 PFC patients treated with LAMS, 94 had DPDS, 71 had intact pancreatic ducts, and duct patency was unknown in 23. In patients with DPDS, replacement of LAMS with plastic stents was successful in 70 patients (74.5%) and technically unsuccessful in 24 patients (25.5%). At a median follow up of 183 days (interquartile range, 179-188 days), although none of the patients with an intact duct had a recurrence of PFC, 7 of the 94 patients with DPDS had recurrence of PFC (7.4%) (P = .020). PFC recurred in 1 of 70 patients with DPDS in whom replacement of LAMS with plastic stent was successful (1.4%) and in 6 of 24 patients with unsuccessful stent replacement (25.0%) (P = .001). In treatment of PFCs with LAMS in patients with DPDS, it is important to replace the LAMS with indwelling plastic stents to minimize PFC recurrence and reduce morbidity. Clinicaltrials.gov no: NCT02422095.

Innovation of EUS-guided transmural gallbladder drainage using a novel self-expanding metal stent

Endoscopic ultrasonography (EUS)-guided transmural drainage has been accepted as a modality of choice in peripancreatic fluid collection and acute cholecystitis. Each type of stent, including double-pigtail plastic stents, tubular self-expandable metal stents (SEMS), and lumen-apposing metal stents, for these procedure has its own advantages and disadvantages. To overcome their disadvantages, this animal study evaluated the feasibility of a newly designed twisted fully covered SEMS with spiral coiled ends. We performed the EUS-guided cholecystogastrostomy with a newly developed metal stent in eight mini pigs with surgically induced gallbladder distension. This novel stent is a twisted fully covered SEMS with spiral coiled ends, a diameter of 8 mm, and a length of 6 cm. The stent has been maintained for four to seven weeks after EUS-guided cholecystogastrostomy. The primary outcome was the technical success rate, and the secondary outcomes were adverse events, stent dysfunction, stent removability, and fistula formation. The stent was placed successfully between the gallbladder and the stomach in all cases without any adverse event. We observed neither stent migration nor dysfunction during the study period, and all the stents were removed easily as scheduled. We confirmed successful cholecysto-gastric fistula formation at endoscopic and histologic level in all cases. EUS-guided transmural drainage and fistula formation using a new twisted fully covered metal stent with spiral coiled ends was technically feasible without any adverse event in this animal study. Further clinical studies are needed to evaluate its efficacy and safety in real practice.

Sa1451 INTERMEDIATE AND LONG TERM SAFETY OF TRANSMURAL DOUBLE PIG-TAIL PLASTIC STENTS FOR MANAGEMENT OF DISCONNECTED PANCREATIC DUCT SYNDROME AND PANCREATIC DUCT DISRUPTION

Necrotizing pancreatitis and chronic pancreatitis can result in disconnected pancreatic duct syndrome and pancreatic duct disruption which may require long term drainage. Surgical management of these conditions carries high risk for morbidity and mortality. European guidelines recommend long term placement of double pigtail plastic stents (DPPS) however data regarding long term safety of this approach is very limited. This study evaluates long term safety and efficacy of DPPS. A single center retrospective case series was performed at a tertiary referral center. Inclusion criteria were patients who underwent endoscopic ultrasound (EUS) guided placement of DPPS for disconnected pancreatic duct syndrome and pancreatic duct disruption from 1/1/2015 to 8/31/2019. Safety and efficacy of DPPS was assessed with retrospective chart review for complications resulting from DPPS including bleeding, infection, perforation and whether stent spontaneously migrated. Chart review also performed to assess for recurrence of fluid collections, and need for surgical intervention due to failure of DPPS drainage. 38 patients had DPPS placed for long term drainage for disconnected pancreatic duct and pancreatic duct disruption. Median age was 51 years; 65% of subjects were male. Etiology of pancreatitis was idiopathic (14/38) and gallstone (13/38). 21/38 (55%) patients had history of walled of necrosis and 17/38(45%) had pseudocyst. Median length of time stents were left in place was 378 days (range 20-1189). One patient had internal migration of stent which was related to interventional radiology manipulation of a percutaneous drain pulling the DPPS into the necrotic cavity – the DPPS was retrieved with endoscopy. 10 patients had asymptomatic spontaneous luminal migration of DPPS. 2 out of these 10 had recurrent fluid collections that did not require repeat drainage. One patient underwent upsizing of DPPS stent for persistent fluid collection with clinical improvement. There were no serious adverse events related to DPPS including perforation, bleeding, fistulas. No patients needed to have surgical intervention for clinical failure of DPPS. Intermediate and long term placement of indwelling DPPS appears to be a safe and highly efficacious surgery sparing approach for pancreatic duct disruption and disconnected pancreatic duct syndrome with minimal complications and low rate of re-intervention.

Tu1027 SAFETY AND EFFICACY OF LUMEN-APPOSING METAL STENTS VERSUS PLASTIC STENTS FOR TREATMENT OF WALLED-OFF PANCREATIC NECROSIS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Walled-off necrosis (WON) is a severe complication of pancreatitis with a high risk of infection or death. Symptomatic WON has typically been treated by drainage using double-pigtail plastic stents (DPPS). More recently, lumen-apposing metal stents (LAMS) were introduced with the intention of improving drainage of solid necrosis and allowing through-the-LAMS necrosectomy. Prior studies have reported similar efficacy of LAMS and DPPS for the treatment of WON. However, some small studies have suggested that LAMS are associated with an increased risk of bleeding compared to DPPS for the treatment of WON. Our primary aim was to conduct a systematic review and meta-analysis to compare the most widely used LAMS to DPPS for WON drainage, with an emphasis on stent-related safety outcomes. Our secondary aim was to document safety and efficacy outcome definitions across studies. Studies were identified from a published 2018 meta-analysis and from searches of the Ovid EBM Reviews (Embase, MEDLINE, Cochrane) and Scopus databases through October 9, 2019. Randomized controlled trials (RCT), cohort studies, case-control studies, and case series that assessed the AXIOS LAMS (Boston Scientific, Marlborough, MA) or DPPS for WON drainage were reviewed. Studies were excluded if they did not use the 2012 Atlanta criteria for WON diagnosis, if they used surgical or percutaneous drainage, reported interim study results, reported on ≤5 patients, or had overlapping study populations. Quality was assessed using the Newcastle Ottawa Scale. Safety and efficacy outcomes were assessed using a random-effects meta-analysis to estimate the proportion of patients with the measure or mean of the measure. Heterogeneity was assessed across studies using the I2 statistic. Data from 2053 patients who participated in 37 observational studies and one RCT were analyzed. Bleeding (4.3% vs. 12.1%, P=0.003; Figure 1) and perforation risk (2.1% vs. 4.3%, P=0.045) were found to be lower in the LAMS group than in the DPPS group. Similar numbers of procedures to achieve resolution (2.09 vs. 1.83, P=0.64) and similar rates of WON resolution (86.4% vs. 82.0%, P=0.20; Figure 2), stent migration (7.8% vs. 6.1%, P=0.54) and stent occlusion (6.2% vs. 13.2%, P=0.086) were found for LAMS compared to DPPS. Outcome definitions differed and were inconsistently reported across studies. Compared with DPPS, the LAMS most commonly used for WON drainage was associated with decreased bleeding and perforation risk and a similar WON resolution rate. Outcome definitions were variable across studies, and only one randomized trial was identified. Additional randomized studies with consistent outcome definitions could better inform the clinical management of WON.Figure 2WON resolution in patients treated with LAMS vs. DPPSView Large Image Figure ViewerDownload Hi-res image Download (PPT)

Su1526 ENDOSCOPIC TRANSPAPILLARY GALLBLADDER DRAINAGE FOR ACUTE CHOLECYSTITIS USING TWO GALLBLADDER STENTS (DUAL GB STENTING)

The mainstay of management of acute cholecystitis has been surgical. Management of acute cholecystitis in patients deemed a high risk for surgical intervention includes endoscopic (transpapillary or transmural stenting) or percutaneous drainage of the gallbladder (GB). One of the major long-term advantages of endoscopic transpapillary GB drainage (ETPGBD) is the absence of anatomic distortion; if the patient’s overall condition improves the patient can undergo surgery without additional challenges. Solitary transpapillary GB stents can get obstructed resulting in recurrence, with studies recommending protocolized replacement. Alternatively, dual GB stenting with 2 transpapillary stents has been described with an additional advantage of having a second stent as well as enhanced capillary action between and along the outer surface of the stents (“wicking effect”) allowing for adequate long-term drainage. This study aims to evaluate the technical feasibility, efficacy, and safety of ETPGBD using dual stents for acute cholecystitis. A retrospective analysis of all patients undergoing ETPGBD using dual stents for acute cholecystitis at our institution between 12/1/2016 and 11/1/2019 was conducted. We abstracted and analyzed patient demographics, endoscopic, imaging, clinical management, and follow-up data to evaluate technical and clinical success, adverse events, and long-term outcomes. The patients underwent endoscopic retrograde cholangiopancreatography (ERCP) with ETPGBD. Two stents were placed either during the index ERCP or a 2nd stent was placed on repeat ERCP typically performed 4-6 weeks after the index stent placement. A total of 46 patients underwent ETPGBD of which 16 patients underwent dual stent placement for long-term GB drainage. (Figure 1) The patients were predominantly male (62.5%) with a mean age of 63.75±15.39 years. A total of 32 stents were placed in these patients; of which 72% (23/32) were 7 Fr in size while the remaining 28% (9/32) were 6 Fr in size. All stents were soft, low-profile, 22 cm long double-pigtail plastic stents. The median interval between the placement of first and second GB stent was 41 days (range 21-224; mean 59.75±51.94). Technical and clinical success was 100% with no evidence of recurrent cholecystitis or biliary obstruction during the median follow-up of 8.7 months (range: 1.4-24.2; mean 9.51±7.58). There were no procedure-related adverse events. ETPGBD with dual GB stents is an effective and safe technique for long-term GB drainage in non-surgical candidates with acute cholecystitis. Larger controlled studies are needed to further validate our findings for widespread implementation of this technique.

Su1296 STEP WISE ANTEGRADE TREATMENT FOR HEPATICOJEJUNOSTOMY ANASTOMOTIC STRICTURE VIA EUS GUIDED HEPATICOGASTROSTOMY

Treatment of Hepaticojejunostomy (HJ) anastomotic stricture is always challenging. Current treatment such as enteroscopy-assisted ERCP is not always successful and might not be suitable for repeated endoscopic dilation. EUS guided hepaticogastrostomy (EUS HGS) is now an alternative biliary drainage method for benign biliary stricture but the treatment approach of this technique is still not well established. We retrospectively studied 7 patients with post-surgery HJ stricture who received EUS HGS approach after failed balloon-assisted enteroscopic drainage. In all cases, connection between left and right intrahepatic bile duct were confirmed by CT scan to ensure the maximal benefit of EUS HGS. Initial EUS HGS was performed using fully covered metallic stent (SEMS) 10x100 mm in 6 cases and 6x100 mm in one case. After tract maturation, SEMS were removed and anastomotic area was cannulated through the EUS HGS fistula. The anastomosis was dilated and multiple 7fr double pigtail plastic stents were placed from the jejunum to the stomach lumen across the stricture site (figure 1). The stents were exchanged every 2-4 months and lithotripsy was performed through HGS in case with intrahepatic duct stone following the treatment protocol (figure 2). The median age was 43 (32 -81). Overall 9 EUS HGS procedures were successfully performed in 7 patients. Stent migration occur in one patient who received 6x100 mm stent placement and in another patient who loss to follow up. In later cases, only 10x100 mm SEMS were used and SEMS were fixed to the stomach using hemoclips. During the subsequent procedure, cannulation across the stricture was performed using balloon occluded cholangiogram, rotatable sphincterotome or direct cholangioscope. HJ was successfully cannulated in the second procedure in 6 patients and we experienced one case of failed cannulation due to severe stricture and intrahepatic bile duct stone. No migration was seen after plastic stent placement. HJ stricture improved in cases that the HJ could be cannulated (6/7 patients) and all patients achieve complete biliary drainage. Complication included mild cholangitis after EUS HGS in all cases which was treated only by antibiotics. Median follow up time was 8.5 months (range 4-30 months). Antegrade treatment for HJ stricture via EUS HGS should be performed in step wise fashion. Migration after initial metallic stent placement is common so stent fixation and stent exchange to plastic stent should be followed after tract maturation.Flow chart demonstrate step wise treatment for hepaticojejunostomy strictureView Large Image Figure ViewerDownload Hi-res image Download (PPT)

Su1314 INNOVATION OF EUS-GUIDED TRANSMURAL GALLBLADDER DRAINAGE USING A NOVEL SELF-EXPANDING METAL STENT

Endoscopic ultrasonography (EUS)-guided transmural drainage has been accepted as a modality of choice in peripancreatic fluid collection and acute cholecystitis. Each type of stent, including double-pigtail plastic stents, tubular self-expandable metal stents (SEMS), and lumen-apposing metal stents, for these procedure has its own advantages and disadvantages. To overcome their disadvantages, this animal study evaluated the feasibility of a newly designed twisted fully covered SEMS with spiral coiled ends. We performed the EUS-guided cholecystogastrostomy with a newly developed metal stent in eight mini pigs with surgically induced gallbladder distension. This novel stent is a twisted fully covered SEMS with spiral coiled ends, a diameter of 8 mm, and a length of 6 cm. The stent has been maintained for four to seven weeks after EUS-guided cholecystogastrostomy. The primary outcome was the technical success rate, and the secondary outcomes were adverse events, stent dysfunction, stent removability, and fistula formation. The stent was placed successfully between the gallbladder and the stomach in all cases without any adverse event. We observed neither stent migration nor dysfunction during the study period, and all the stents were removed easily as scheduled. We confirmed successful cholecysto-gastric fistula formation at endoscopic and histologic level in all cases. EUS-guided transmural drainage and fistula formation using a new twisted fully covered metal stent with spiral coiled ends was technically feasible without any adverse event in this animal study. Further clinical studies are needed to evaluate its efficacy and safety in real practice.

The role of solid debris in endoscopic ultrasound-guided drainage of walled-off necrosis: A large cohort study.

The effect of solid debris on walled-off necrosis (WON) drainage remains unknown. Our study evaluated the role of solid debris in endoscopic ultrasound (EUS)-guided drainage of WON compared lumen-apposing metal stent (LAMS) with double-pigtail plastic stent (DPPS). We retrospectively evaluated consecutive patients with WON who underwent EUS-guided drainage in our endoscopic center over a 9-year period. The amount of solid debris in WON was assessed with computed tomography or magnetic resonance imaging and EUS images. From 2011 to 2019, 84 WON patients were included. In WON with <20% solid debris, the short-term clinical success of LAMSs (96.8%) was significantly higher than DPPSs (66.7%) (P=0.03), and LAMSs were safer than DPPSs with less early adverse events (P=0.02) and late adverse events (P=0.03). On multivariable analysis, DPPS (odds ratio [OR], 0.16; 95% confidence interval [CI], 0.04-0.65; P=0.01) and solid debris >40% (OR, 0.11; 95% CI, 0.02-0.62; P=0.01) were the predictors for failure of resolution of WON after adjusting for age and cyst size. The number of DPPSs used was significantly higher than LAMSs in managing WONs (P<0.001). For WON with <20% solid debris, LAMSs might superior to DPPSs in terms of efficacy and safety.