Double Stent Placement Research Articles

Coaxial plastic stent placement within lumen-apposing metal stents for the management of pancreatic fluid collections: a systemic review and meta-analysis.

Coaxial placement of double pigtail plastic stents (DPPS) through lumen-apposing metal stents (LAMSs) is commonly performed to reduce the risk of LAMS obstruction, bleeding, and stent migration when used for the drainage of pancreatic fluid collections (PFCs). A systematic review and meta-analysis were performed to compare the outcomes of LAMS alone and LAMS with coaxial DPPS placement in the management of PFCs. A systematic review was conducted to identify studies comparing LAMS and LAMS/DPPS for PFC drainage. Primary outcomes included the rate of clinical success, overall adverse events (AEs), bleeding, infection, occlusion, and stent migration. The pooled effect size was summarized using a random-effects model and compared between LAMS and LAMS/DPPS by calculating odds ratios (ORs). Nine studies involving 709 patients were identified (338 on LAMS and 371 on LAMS/DPPS). LAMS/DPPS was associated with a reduced risk of stent obstruction (OR, 0.59; p=0.004) and infection (OR, 0.55; p=0.001). No significant differences were observed in clinical success (OR, 0.96; p=0.440), overall AEs (OR, 0.57; p=0.060), bleeding (OR, 0.61; p=0.120), or stent migration (OR, 1.03; p=0.480). Coaxial DPPS for LAMS drainage of PFCs is associated with a reduced risk of stent occlusion and infection; however, no difference was observed in the overall AE rates or bleeding.

S2848 Massive Pseudo-Pneumoperitoneum After Endoscopic Necrosectomy

Introduction: Encapsulated peripancreatic fluid collection and walled-off necrosis are some of the complications of acute pancreatitis. Most resolve spontaneously but symptomatic pseudocysts or walled-off necrosis require drainage. The preferred therapeutic management is endoscopic ultrasound (EUS) guided drainage with stent placement. Known iatrogenic complications of the procedure include bleeding and perforation. Case Description/Methods: A 39-year-old woman with history of ulcerative colitis, in remission on certrolizumab presented with symptomatic walled-off necrosis after idiopathic necrotizing pancreatitis. EUS-guided drainage and stent placement was successfully performed. On subsequent upper endoscopy for necrosectomy, post-procedure large pneumoperitoneum was noted on imaging leading to emergent surgical evaluation with laparoscopy. However, no perforation or pancreatic fluid contamination was seen. On post-operative day 1, patient was asymptomatic and tolerating diet. She was discharged on post-operative day 2. At 3-month follow-up, patient remained asymptomatic and plastic stents were removed. Discussion: Pneumoperitoneum is an uncommon but dreaded complication of EUS guided cystogastrostomy. This occurs when there is separation of the gastric wall and the wall of the pancreatic cyst or walled-off necrosis. If perforation is detected during cystgastrostomy, it may be possible to use a LAMS to close the defect by bridging the walls or close the gastric defect endoscopically with clips or sutures. Immediate surgery (such as cyst-enterotomy with closure of the wall defect) should be performed if there is generalized contamination of the peritoneum with cyst fluid content and subsequent signs of peritonitis. (Figure) Our case, to our knowledge, is the only one that describes pneumoperitoneum after endoscopic necrosectomy, two weeks after placement of LAMS. Our hypothesis is that the walled-off necrosis moved away from the gastric wall after removal of LAMS, which had aided apposition of the gastric wall and cyst wall due to its flanges and short saddle length. Pneumoperitoneum, in the absence of peritoneal findings, is referred to as benign peritoneum. Our case describes massive benign pneumoperitoneum after endoscopic necrosectomy without perforation. There is a paucity of literature on non-surgical management of post-endoscopic pneumoperitoneum and we hope that our case, will help endoscopists carefully select patients who will benefit from surgical management of pneumoperitoneum.Figure 1.: Figure A. CT abdomen showing pancreatic walled off necrosis containing turbid fluid and debris. Figure B. Massive pneumoperitoneum seen on CT abdomen after EUS-guided drainage and double pig-tailed stent placement for continued drainage.

S2835 Gastro-Cholecysto-Colonic Fistula Following Endoscopic Ultrasound-Guided Gallbladder Drainage for Stump Cholecystitis: A Case Report

Introduction: Cholecystocolonic fistulas (CCF) usually occur as a complication of gallstones but cases due to malignancy, peptic ulcers, and Crohn’s disease have been reported. We present a case of a gastro-cholecysto-colonic fistula after endoscopic ultrasound guided-gallbladder drainage (EUS-GBD) for stump cholecystitis. Case Description/Methods: A 50 year old male presented with abdominal pain. CT scan noted acute cholecystitis. He underwent laparoscopic converted to open subtotal cholecystectomy due to significant inflammation around the gallbladder. He represented 3 weeks later for abdominal pain. CT showed stump cholecystitis. Gastroenterology was consulted for EUS-GBD given his poor surgical candidacy. Diagnostic EUS revealed choledocholithiasis. Endoscopic retrograde cholangiography (ERC) with cholangioscopy, electrohydraulic lithotripsy, and stone removal was completed. Transgastric EUS-GBD with a 10 x 10 mm electrocautery enhanced lumen apposing metal stent (LAMS) was then performed followed by double pigtail stent (DPT) placement within the LAMS. At a follow up visit, abdominal pain resolved but he developed debilitating diarrhea and was started on cholestyramine. Upper endoscopy 4 weeks after EUS-GBD revealed a gastro-cholecysto-colonic fistula with the proximal end of the DPT in the colon. Cholecystoscopy confirmed absence of gallstones so the LAMS and DPT were removed. Clips were used to close the cholecystogastric tract. Oral contrasted CT with delayed images showed tethering of the gallbladder to the hepatic flexure but no extravasation of contrast into the gallbladder from either the stomach or colon. Given this, clinical observation was pursued. Six weeks later, CT noted similar tethering without contrast leak. On colonoscopy, an area of inflamed mucosa at the hepatic flexure was seen without a patent fistula tract. Biopsies showed chronic colitis. Diarrhea subsequently resolved. (Figure) Discussion: CCFs are a rare complication of gallstone disease. If untreated, biliary sepsis can occur. Surgery is the standard treatment but endoscopic transpapillary gallbladder drainage with a DPT can promote fistula healing in non-surgical patients. We present a case of a gastro-cholecysto-colonic fistula in a poor surgical candidate after EUS-GBD for stump cholecystitis. This was managed with closure of the cholecystogastric tract. CCF closure occurred spontaneously. In cases of persistent CCF, transpapillary gallbladder drainage should be considered.Figure 1.: A. Double pigtail stent migrated into transverse colon with gastro-cholecysto-colonic fistula as viewed from the gallbladder lumen. B. CT scan showing tethering of hepatic flexure to remnant gallbladder (red arrow) without contrast extravasation into the gallbladder from the stomach or colon. C. Closed cholecystocolonic fistula (black arrow) viewed from the hepatic flexure.

Sequential double stent placement using the stent-pushing-stent technique over a single wire during double-balloon ERCP.

Sequential double stent placement using the stent-pushing-stent technique over a single wire during double-balloon ERCP.

Double pigtail stent placement as an adjunct to lumen-apposing metal stentsfor drainage of pancreatic fluid collections may not affect outcomes: A multicenter experience.

Background and Objectives:EUS-guided drainage of pancreatic fluid collections (PFCs) has been increasingly performed using lumen-apposing metal stents (LAMS). However, recent data have suggested higher adverse event rates with LAMS compared to double pigtail plastic stents (DPS) alone. To decrease risks, there has been anecdotal use of placing DPS through the LAMS. We aimed to determine whether the placement of DPS through cautery-enhanced LAMS at time of initial placement decreases adverse events or need for reintervention.Methods:We performed a multicenter retrospective study between January 2015 and October 2017 examining patients who underwent EUS-guided drainage of pseudocysts (PP), walled-off necrosis (WON), and postsurgical fluid collection using a cautery enhanced LAMS with and without DPS.Results:There were 68 patients identified at 3 US tertiary referral centers: 44 PP (65%), 17 WON (25%), and 7 PFSC (10%). There were 35 patients with DPS placed through LAMS (Group 1) and 33 with LAMS alone (Group 2). Overall technical success was 100%, clinical success was 94%, and adverse events (bleeding, perforation, stent occlusion, and stent migration) occurred in 28% of patients. Subgroup analysis compared specific types of PFCs and occurrence of adverse events between each group with no significant difference detected in adverse event or reintervention rates.Conclusion:This multicenter study of various types of PFCs requiring EUS-guided drainage demonstrates that deployment of DPS across cautery-enhanced LAMS at the time of initial drainage does not have a significant effect on clinical outcomes, adverse events, or need for reinterventions.

Neoadjuvant double metal stent placement in a patient with locally unresectable cancer of the panceatic head—a case report

Neoadjuvant double metal stent placement in a patient with locally unresectable cancer of the panceatic head—a case report

S1521 Ectopic Location of the Ampulla of Vater in the Pyloric Channel

INTRODUCTION: The ampulla of Vater can be ectopically located in stomach, pylorus, or duodenum with the duodenum comprising the majority of cases. The prevalence of this abnormality is rare, nonetheless it has important clinical ramifications. Given the unusual anatomy, patients may be at higher risk of ulceration, stenosis, and choledocholithiasis while accompanying ERCP can be more challenging and time consuming. CASE DESCRIPTION/METHODS: A 90-year-old gentleman presented to his PCP with 4 weeks of RUQ abdominal pain. His past medical history was significant for a non-healing pyloric channel ulcer resulting in gastric outlet obstruction, initially treated with balloon dilation and subsequently with gastrojejunostomy. Laboratory examination showed a total bilirubin of 0.7, ALP 877, AST 129, and ALT 168. MRCP revealed a dilated bile duct to 15 mm with a large stone seen in the distal CBD. On ERCP, the gastrojejunostomy appeared patent without ulceration or stenosis. However, a 1.5 cm pyloric channel ulcer was seen resulting in pyloric stenosis (Figure 1). This was successfully dilated to 15 mm using a wire guided balloon with subsequent advancement of the duodenoscope into the second portion of the duodenum. After careful inspection, the ampulla was eventually discovered to be ectopically located in the pyloric channel with surrounding ulceration (Figure 2). Cholangiogram showed a large stone within the bile duct, which was treated with balloon sphincteroplasty, balloon sweeps with stone removal, and a double pigtail stent placement (Figure 3). The patient was subsequently started on high dose PPI therapy. Repeat ERCP in 3 months showed complete healing of the pyloric channel ulcer and a normal cholangiogram with no residual stones. Patient had repeat LFT’s 6 weeks post-procedure which were normal. DISCUSSION: Ectopic major papilla in the pyloric channel can lead to pyloric channel ulceration secondary to mucosal injury caused by chronic flow of bile and pancreatic digestive enzymes to this region. The anomalous bile drainage also increases the predisposition for development of choledocholithiasis. Balloon sphincteroplasty is the preferred method of stone removal in these patients given the increased perforation risk of sphincterotomy due to lack of anatomical landmarks.Figure 1.: Pyloric channel ulcer resulting in GOO.Figure 2.: Ectopic ampulla of Vater with bile duct (red arrow) and pancreatic duct (green arrow) opening.Figure 3.: Balloon sphincteroplasty (red arrow showing CBD stone).

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.

MP22-13 DOUBLE URETERAL STENT PLACEMENT REDUCES RESTENOSIS AFTER INCISION AND DILATATION FOR URETERAL STENOSIS

INTRODUCTION AND OBJECTIVE: Laser incision (laser endoureterotomy: LE) and balloon dilatation (BD) are the treatments for ureteral strictures measuring ≤20 mm; however, these treatments are associated with a high risk of postoperative restenosis. Endoscopic management of benign ureteral strictures has been described in the adult literature with failure rates of 12% to 38%. Therefore, this study aimed to investigate the effectiveness of a novel method to place double ureteral stents after LE and BD. METHODS: In total, 10 patients who underwent endoscopic surgery for ureteral stenosis from January 2016 to March 2019 were included. All stenoses were iatrogenic rather than congenital. In LE, the stenosis site, including 2 mm before and after the site, was incised using a laser until the fat tissue outside the ureter was visible. A flexible ureteroscope was used for upper ureteral stenosis and a semi-rigid ureteroscope was used for middle or lower ureteral stenosis. In BD, the stenosis site was dilated with a balloon up to 15 Fr. In all cases, two 4.7-Fr ureteral stents were placed and removed 4–8 weeks after surgery. The improvement of hydronephrosis, surgical parameters, and complications were evaluated. RESULTS: The stenosis site was confirmed in the upper ureter in six patients; in the middle ureter in three patients; and in the lower ureter in one patient, with an average distance of 9.7 ± 5.6 mm. Preoperative hydronephrosis was grade G1 in one patient, grade G2 in one patient, grade G3 in four patients, grade G4 in four patients, and improved in nine patients (90%) 3 months after surgery. The average duration of surgery was 111 ± 21 minutes, and no surgical complications over grade 3 were observed. The average duration of hospital stay was 4.1 ± 0.5 days. The mean follow-up period was 661 ± 405 days, and no restenosis was observed in any of the eight patients. CONCLUSIONS: Placement of double ureteral stents after surgery for ureteral stenosis was effective. Source of Funding: none

Laparoscopic Sleeve Gastrectomy Leakage: Case Report of A Rare Complication Management

Introduction: Laparoscopic sleeve gastrectomy (SG) is an effective method for the treatment of obesity. Leakage is the most common and unfavorable complication of SG. Use of self-expandable metal stents (SEMS) has become the gold standard management. Aortoesophageal fistula (AEF) is a rare and life-threatening complication that can result from SEMS placement. Case Presentation: A 52 year old woman underwent laparoscopic SG for morbid obesity. Eight days after an esophagogastric SEMS placement was required for gastric leakage. Twenty two days later she presented massive hematemesis and active AEF was diagnosed requiring endovascular placement of thoracic endoprosthesis. SG conversion into Roux en Y gastric bypass (RYGB) with double pigtail stent placement was necessary for the persistence of gastric fistula. 45 days after, EGD revealed the aortic prosthesis at the distal portion of esophagus. For this reason, she underwent a thoracic aorta reconstruction and an esophago jejunal anastomosis. Discussion: Esophageal ulceration is a possible complication of SEMS placement and can lead to an AEF. In order to promptly identify and treat rare and fatal complications as AEF, it is important to always keep a high index of suspicion. Conclusion: The awareness of rare complications as AEF after SEMS placement is important in order to facilitate immediate surgical treatment and to raise survival possibility. It is important to be familiar with all different treatment options, as well as being updated on the latest Guidelines. A good knowledge of timing and best treatment option, depending on the leak and patient clinical status, are mandatories.

1896 Jejunal Migration of Double Pigtail Stent Successfully Removed by Enteroscopy

INTRODUCTION: Walled-off pancreatic necrosis, pseudocyst, and intra-abdominal abscess are common complications after pancreatectomy. Based on the location, the endoscopic drainage can be performed with placement of double pigtail stents. However, the stent itself can cause distal migration months to years later, and it can lead to viscera perforation if not removed in a timely fashion. CASE DESCRIPTION/METHODS: We present a case of a 63-year-old woman with history of pancreatic adenocarcinoma status post distal pancreatectomy, splenectomy and partial gastrectomy. Post-surgery, she developed peri-pancreatic fluids collection posterior to the stomach. She underwent cyst duodenostomy, cyst gastrostomy, serial necrosectomies, and sequential placement of AXIOS LAMS (lumen apposing metal stents) and double pigtail plastic stent. LAMS were removed serially after the drainage but double pigtail stent was left behind. A year and half later, she presented to our hospital with left upper abdominal pain for four days. The pain was sharp, stabbing, radiated to left flank, and worsened with deep inspiration and body movements. The review of systems was not significant. She was afebrile and vitals were stable. Physical exam was only significant for moderate tenderness in left upper quadrant and left flank region. Labs showed leukocytosis, thrombocytosis, but normal kidney and liver functions. CT abdomen and pelvis with contrast showed distally migrated double pigtail stent in the mid-jejunum. Enteroscopy using the colonoscope was introduced into the mid-jejunum. A foreign body consistent with the double pigtail stent was found. It was removed with rat-toothed forceps. No perforation was evident post procedure. The abdominal pain resolved completely several hours after the procedure. DISCUSSION: Distal stent migration is a possible remote complication if the double pigtail stent remained after complete drainage of intra-abdominal abscesses or pseudocysts. Endoscopic removal is a safe and effective procedure provided that there is no bowel perforation.

Endovascular reconstructive treatment using a fill-and-tunnel technique for a fusiform vertebral artery dissecting aneurysm with ipsilateral dominance.

Fusiform dissecting aneurysms involving the dominant vertebral artery with poor collaterals are challenging to treat. The purpose of this study was to present an initial experience with a fill and tunnel technique for reconstructive endovascular treatment of these conditions. A total of 13 patients, 11 men and 2 women, each with a fusiform vertebral artery dissecting aneurysm not amenable to internal trapping of the parent artery, underwent reconstructive endovascular treatment using a fill and tunnel technique between January 2012 and December 2015. The safety, feasibility, and clinical and angiographic outcomes of these procedures were retrospectively evaluated. The average maximum diameter of the fusiform aneurysms was 12.1 mm. Five were ruptured. Three aneurysms were treated with a single stent and the remaining 10 aneurysms required double-stent placement. Treatment was technically successful in all 13 patients, achieving complete occlusion (n = 10, 76.9%) and near-complete occlusion (n = 3, 23.1%). No procedure-related complications occurred in any patient. There were no delayed thromboembolic or hemorrhagic complications during the follow-up period (mean, 19.0 months). Angiographic follow-ups (mean, 9.1 months) showed stable occlusion in 90.9% (10/11) and asymptomatic in-stent occlusion in one patient (9.1%, 1/11). At the end of the observation period (mean, 19.0 months), all patients had excellent clinical outcomes (modified Rankin Scale (mRS) 0, 92.3%, 12/13), except one (mRS 4), resulting from poor preoperative status. This retrospective study demonstrated that endovascular reconstruction using a fill-and-tunnel technique was a technically safe, feasible, and clinically effective treatment method for fusiform vertebral artery dissecting aneurysms with ipsilateral dominance.

Complications of Long-Term Indwelling Transmural Double Pigtail Stent Placement for Symptomatic Peripancreatic Fluid Collections.

Endoscopic transmural drainage is performed for symptomatic peripancreatic fluid collections (PPFCs). Long-term transmural double-pigtail stent (DPS) placement is useful in preventing recurrences. There are few reports on the long-term safety of DPS placement. Thus, this study aimed to examine the complications of long-term indwelling DPS for PPFCs. Among 53 patients who underwent endoscopic ultrasound-guided transmural drainage for symptomatic PPFCs between April 2006 and March 2017, those followed up for over one year were included. Complications of long-term indwelling DPS were examined retrospectively. This study enrolled 36 patients [30 men, median age 54years (range 22-82)]. Walled-off necrosis was present in 22 cases (including 9 disconnected pancreatic duct syndrome cases) and pancreatic pseudocysts, in 14 cases. The median stenting period was 20.9 (range 0.8-142.3) months, and median observation period was 56.2 (range 12.4-147.1) months. Colon perforation due to DPS occurred in 3 cases (8.3%), at 5.8, 17.1, and 33.7months after indwelling DPS placement; 2 cases developed perforation from the serosal side. In 1 case, the patient was treated surgically, and in 2 cases, the patients underwent endoscopic removal of the stent and showed improvement with conservative treatment. Long-term indwelling transmural DPS for symptomatic PPFCs poses a risk of intestinal perforation. Thus, if possible, it may be better to avoid long-term placement.

Successful treatment for infected biloma after endoscopic ultrasound-guided hepaticogastrostomy using double stent placement technique

Successful treatment for infected biloma after endoscopic ultrasound-guided hepaticogastrostomy using double stent placement technique

Outcomes of endoscopic biliary drainage in pancreatic cancer patients with an indwelling gastroduodenal stent: a multicenter cohort study in West Japan

Gastroduodenal and biliary obstruction may occur synchronously or asynchronously in advanced pancreatic cancer, and endoscopic double stent placement may be required. EUS-guided biliary drainage (EUS-BD) often is performed after unsuccessful placement of an endoscopic transpapillary stent (ETS), and EUS-BD may be beneficial in double stent placement. This retrospective multicenter cohort study compared the outcomes of ETS placement and EUS-BD in patients with an indwelling gastroduodenal stent (GDS). We recorded the clinical outcomes of patients at 5 tertiary-care medical centers who required biliary drainage after GDS placement between March 2009 and March2014. Thirty-nine patients were included in this study. Patients' mean age was 68.5 years; 23 (59.0%) were men. The GDS overlay the papilla in 23 patients (59.0%). The overall technical success rate was significantly higher with EUS-BD (95.2%) than with ETS placement (56.0%; P< .01). Furthermore, the technical success rate was significantly higher with EUS-BD (93.3%) than with ETS placement (22.2%; P< .01) when the GDS overlies the papilla. The overall clinical success rate of EUS-BD also was significantly higher than for ETS placement (90.5% vs 52.0%, respectively; P= .01), and there was no significant difference in the incidence of adverse events (ETS, 32.0% vs EUS-BD, 42.9%; P= .65). Endoscopic double stent placement with EUS-BD is technically and clinically superior to ETS placement in patients with an indwelling GDS. EUS-BD should be considered the first-line treatment option for patients with an indwelling GDS that overlies the papilla. ETS placement remains a reasonable alternative when the papilla is not covered by the GDS.

Tu1499 Use of a Double-Pigtail Stent to Prevent Migration of Fully Covered Metal Stents in Biliary Strictures: A Retrospective Analysis

Migration has been reported in up to 37.5% of patients with fully-covered self-expandable metal stent (FCSEMS). Placement of plastic double pigtail stents within FCSEMS may decrease migration. In this study, we aim to compare stent migration rates in patients with biliary strictures who receive FCSEMS alone to those who receive both a FCSEMS and an anchoring plastic stent (PS).

A Comparison of Magnetic Resonance Angiography Techniques for the Evaluation of Intracranial Aneurysms Treated With Stent-assisted Coil Embolization.

AimTo identify the effective magnetic resonance angiography (MRA) technique to monitor intracranial aneurysms treated with stent-assisted coiling.Materials and MethodsRetrospective analysis of various MRA techniques was performed in 42 patients. Three neuroradiologists independently compared non-contrast time of flight (ncTOF) MRA of the head, contrast-enhanced time of flight (cTOF) MRA of the head and dynamic contrast-enhanced MRA (CEMRA) of the head and neck or of the head. Digital subtraction angiography (DSA) was available for comparison in 32 cases. Inter-rater agreement (kappa statistic) was assessed.ResultsArtifactual in-stent severe stenosis or flow gap was identified by ncTOF MRA in 23 of 42 cases (55%) and by cTOF MRA in 23 of 38 cases (60%). DSA excluded in-stent stenosis or occlusion in all 32 cases. No difference was noted between ncTOF and cTOF in the demonstration of neck remnants or residual aneurysms in three cases each. CEMRA of the head and neck or of the head was rated superior to ncTOF and cTOF MRA by all three investigators in seven out of eight cases. In one case, all three techniques demonstrated signifcant artifacts due to double stent placement during coiling. The kappa statistic revealed 0.8 agreement between investigators.ConclusionsIn the assessment of stent-assisted coiling of intracranial aneurysm, both ncTOF and cTOF MRA show similar results. CEMRA tends to show better flow signals in stent and residual aneurysm.

The application of catheter and guidewire in double J stent placement during retroperitoneal laparoscopic ureterolithotomy

Objectives To explore the experience of double J stent placement using catheter and guidewire in the treatment of upper ureteralic calculi during retroperitoneal laparoscopic ureterolithotomy (RLUL). Methods The clinical data of 26 cases with upper ureteral calculi who und-went retroperitoneal laparoscopic ureterolithotomy in our hospital from July 2014 to November 2015 were retrospectively analyzed. The double J stents were placed by using catheter and guidewire, and the experience of placement was summarized. Results In all cases, the double J stent placement was successful, and the time of it ranged from 2~7 min (mean 3 min). The position of the double J stent was showed normal by the KUB after operation. The double J stent was removed one month after operation, and no cases of postoperative complications were found. Conclusions This approach of double J stent placement during laparoscopic is simple, fast and effective, which is worthy of clinical application. Key words: Ureteral Calculi; Laparoscopes

Single-session double-stent placement in concomitant malignant biliary and duodenal obstruction with a cautery-tipped lumen apposing metal stent.

Single-session double-stent placement in concomitant malignant biliary and duodenal obstruction with a cautery-tipped lumen apposing metal stent.

Are single or dual luminal covered expandable metallic stents suitable for esophageal squamous cell carcinoma with esophago-airway fistula?

To analyze the outcomes of single or dual luminal self-expandable covered metallic stents (SECMS) for palliative treatment for esophageal cancer with esophago-airway fistula (EAF). We retrospectively assessed 50 patients who underwent SECMS placement for malignant EAF at our institution between June 2005 and December 2014 to define clinical results of stenting. Treatment provided was classified into initial single airway, single esophageal, or double stent placement. Independent associations between size, location of the EAF, patient's condition, and the risk of migration or reopening with the different types of stenting were examined using logistic regression analysis. The final management of malignant EAF was esophageal stent in 21 patients, airway stent in 13, and dual stents in 16. No patients failed stenting. During a median follow-up of 178days (range 1-893days), the fistula reopened in 33 (66%) of 50 patients. No factors, including fistula size, location, or initial selection of single or dual stenting, were correlated with reopening. Nineteen (57.6%) of 33 patients needed restenting, and the reopened EAF was sealed off successfully in 52.6% of new stent placements. The clinical failure of EAF closure was correlated only with proximal dilated esophagus (p=0.013). Mean survival in patients with clinical success of EAF closure was also significantly longer than that in patients with clinical failure (242.0 vs. 80.1days, p<0.001). KPS (p=0.026), cough ability (p=0.004), successful closure of EAF (p=0.001), and reopening (p=0.007) all had significant effects on survival. We conclude that SECMS is safe and effective in the palliation of esophageal cancer with malignant EAF, especially in patients with an otherwise excellent general condition. Other modalities of management are recommended for malignant EAF with proximal dilation of the esophagus.