Duration Of Stent Placement Research Articles

Risk factors for bacterial stent colonization in patients with a double J ureteral stent: a prospective study

Background: The increasing use of double-J ureteral stents (DJS) has increased the risk of early intolerance and long-term complications. Studies have reported stent colonization rates ranging from 19% to 90% with various bacterial profiles in the colonization of stents. Objectives: To identify the risk factors associated with bacterial colonization of DJS and report the common microorganisms isolated and drug susceptibility pattern. Methods: This study is a prospective study of patients who underwent DJS. A total of 48 patients from our institution were studied between March 2022 and August 2023. After removal of DJS with a sterile technique, the tips of both ends (renal end and bladder end) of the stent were cut and processed in the microbiology lab. Results: Bacterial colonies were detected in 56.25% (27 out of 48) of the stents. Among the pathogens identified, Enterococcus species, Pseudomonas Aeruginosa and E. coli were the most frequently isolated. The colonization rate increased with the duration of stent placement and albuminuria. Conclusions: The study indicated that prolonged indwelling time and albuminuria are a risk factor for bacterial colonization on the stent therefore, it is advisable to use Double J ureteral stent only when absolutely necessary and to remove them promptly.

Development of irreversible pancreatic ductal change triggered by pancreatic duct stenting in chronic pancreatitis.

Stent-induced ductal change is a complication of endoscopic pancreatic stent placement for chronic pancreatitis, potentially leading to irreversible changes that may contribute to pancreatic dysfunction. This study aimed to examine the long-term outcomes of stent-induced ductal change and evaluate factors that correlate with the development of irreversible ductal changes. Between January 2008 and December 2022, 52/223 patients with chronic pancreatitis in whom an S-type plastic stent was successfully placed from the main papilla for duct stricture were detected with stent-induced ductal change on pancreatography at stent removal. We retrospectively investigated the clinical features of patients whose main pancreatic duct was reassessed by endoscopic pancreatography after >1month without stent and whose residual stent-induced ductal change was irreversible. The patients with chronic pancreatitis with stent-induced ductal change (n=28) (elevated change, 15; stricture change, 13) were evaluated using follow-up pancreatography. Eleven patients (39.3%) showed residual change associated with stent-induced ductal change, the degree of which was partial improvement, no change, and obstructive change in one, seven, and three patients, respectively. Stricture changes during stent removal and duration of stent placement that triggered ductal changes were significantly associated with the development of residual ductal changes. Irreversible stent-induced ductal change in patients with chronic pancreatitis was associated with stricture changes in the main pancreatic duct and continued plastic-stent placement. Careful evaluation of the pancreatic duct is required during plastic-stent placement. Early plastic-stent removal may result in an effective response to the development of stent-induced ductal change.

“Forgotten” Encrusted Ureteral Stents, Combined Endourological Approach

Introduction: Ureteral stents have been widely used for drainage of the upper urinary tract during both emergency and elective surgical procedures since 1967. The main pathology in which these stents are used is urolithiasis.Objective: To present our experience with the surgical treatment of patients with “forgotten” encrusted ureteral stents using a combined endourological approach.Materials and methods: Patients with encrusted ureteral stents who underwent endourological procedures from 2016 to 2022 were prospectively evaluated. They were grouped based on the degree of stent encrustation according to the FECal classification. The duration of stent placement, number and types of surgical procedures, number of procedures before complete removal of the stent and concrements, surgery duration, hospital stay, complications, concrement analysis, and frequency of complete concrement removal per surgery were compared between the groups. The combined endourological procedure was performed with the patient placed in the Galdakao-modified supine Valdivia position. This position allows simultaneous antegrade and retrograde endourological access.Results: The study included 46 patients grouped according to the FECal classification. In 38 patients, stents were successfully removed in a single procedure. The mean operative time, concrement-free status, and complication rate were 90.2 ± 19.8 minutes, 78.3%, and 32.6%, respectively. Total encrustation volume was higher for grades IV and V (5.6 ± 1.8 and 7.6 ± 2 cm3) compared with all the other grades. Percutaneous nephrolithotripsy and cystolithotripsy were the most common procedures in grades IV and V. Lithotripsy was commonly used for ureteral stent encrustation, especially in the groups with grades I and III. The operative time was longer in groups IV-V compared with groups I and II because percutaneous nephrolithotripsy was more frequent in these cases. Retrograde intrarenal surgery was performed in 88% of the cases with the combined approach to check whether concrements were present in the renal calyces and pelvis. In 5 cases, a flexible ureterorenoscope was advanced antegradely through a percutaneous access to disintegrate the encrustation of the proximal part of the stent’s ureteral section. Complications occurred in 32.6% of the patients. Most complications (26%) were minor: fever, pain, or gross hematuria. One case required segmental renal artery embolization for bleeding, and antibiotic therapy associated with an attack of pyelonephritis was adjusted in 2 cases.Conclusions: The endoscopic combined approach in the Galdakao-modified supine Valdivia position is a safe and effective technique that allows removal of “forgotten” encrusted stents, in most cases, in a single procedure. The FECal classification seems to be useful for surgical planning and prognosis.

Antimicrobial and Antiproliferative Coatings for Stents in Veterinary Medicine-State of the Art and Perspectives.

Microbial colonization in veterinary stents poses a significant and concerning issue in veterinary medicine. Over time, these pathogens, particularly bacteria, can colonize the stent surfaces, leading to various complications. Two weeks following the stent insertion procedure, the colonization becomes observable, with the aggressiveness of bacterial growth directly correlating with the duration of stent placement. Such microbial colonization can result in infections and inflammations, compromising the stent's efficacy and, subsequently, the animal patient's overall well-being. Managing and mitigating the impact of these pathogens on veterinary stents is a crucial challenge that veterinarians and researchers are actively addressing to ensure the successful treatment and recovery of their animal patients. In addition, irritation of the tissue in the form of an inserted stent can lead to overgrowth of granulation tissue, leading to the closure of the stent lumen, as is most often the case in the trachea. Such serious complications after stent placement require improvements in the procedures used to date. In this review, antibacterial or antibiofilm strategies for several stents used in veterinary medicine have been discussed based on the current literature and the perspectives have been drawn. Various coating strategies such as coating with hydrogel, antibiotic, or other antimicrobial agents have been reviewed.

Clinical evaluation the success rate and complications of fluoroscopically guided removal of tracheal tube metallic stents

BackgroundLong-term placement of airway stents has a high probability of restenosis of the airway due to granulation tissue hyperplasia, and it is difficult to remove the stent. Our aim is to evaluate the success rate and complications of removal of tracheal tube metallic stents under fluoroscopic guidance, and to compare the difference between uncovered stent and covered stent.MethodsWe retrospectively reviewed 45 cases (31 males and 14 females; age, 12–71 years) of tracheal metallic stent removal performed at our center between January 2014 and December 2019. Covered stents were applied in 36 cases, and uncovered stents were applied in 9 cases. In the covered stent group, 15 patients presented with granulation tissue at both ends; 3 cases, with stent fracture; and 2, with stent intolerance due to severe airway foreign body sensation. In the uncovered stents group, all patients presented with granulation tissue formation; 2 patients, with stent fracture; and 1 patient, with stent intolerance.ResultsA total of 41 (91.1%) stents were successfully removed (34 [94.4%] in the covered stent group and 7 [77.8%] in the uncovered stent group). The average duration of stent placement was 3.2 ± 0.7 and 2.5 ± 1.2 months in the covered stent group and uncovered stent group, respectively. With regard to the complications, hemoptysis occurred in 4 cases (average blood volume lost, 100 ml), tracheal mucosa tear occurred in 5 cases, tracheal collapse requiring emergency airway stent placement occurred in 1 case, and tracheal rupture requiring emergency surgical suture occurred in 1 case. No procedure-related deaths occurred in either group.ConclusionsIt is safe to remove the metal stent of the tracheal tube under the guidance of fluoroscopy, with low complications, and can avoid the long-term placement of the airway stent.

Risk factors for persistent epiphora following successful canalicular laceration repair.

To identify the risk factors of epiphora in patients with anatomical patency after surgical repair of canalicular laceration. This retrospective case series included 178 cases of canalicular laceration repair from 2005 to 2012. Demographic data collected from each patient included age, sex, type of injury, distance from the distal lacerated end of the canaliculus to the punctum, the severity score for the structural abnormity of the medial canthus, the duration of stent placement, and the timing of surgery. The risk factors for epiphora were evaluated using Logistic regression models. Among the 178 cases, 45 (25.3%) with lacrimal patency after irrigation had symptomatic epiphora at the final follow-up. Patients' sex, age, type of injury, duration of stent placement, timing of surgery, and concurrent trauma were not found to be significantly associated with symptomatic epiphora after surgical repair of the lacerated canaliculus (P>0.05). A distance of more than 5 mm from the distal cut end to the punctum was closely and significantly associated with symptomatic epiphora after surgical repair of the lacerated canaliculus (P<0.01). Symptomatic epiphora was significantly more frequent in patients with higher severity scores for structural abnormities of the medial canthus (P<0.01). Our results indicate that the risk factors for postoperative symptomatic epiphora include a further distance between the distal cut end and the lacrimal punctum and a higher severity score for structural abnormities of the medial canthus. These findings could be used to prognosticate postoperative symptomatic epiphora.

MP65-16 CREATION OF A STANDARDIZED HYPOSPADIAS TEMPLATE IN THE ELECTRONIC MEDICAL RECORD

You have accessJournal of UrologyPediatrics: Hypospadias and Penile Surgery (MP65)1 Apr 2020MP65-16 CREATION OF A STANDARDIZED HYPOSPADIAS TEMPLATE IN THE ELECTRONIC MEDICAL RECORD Christopher Long*, Luis Braga, John Wiener, Mark Zaontz, and Melise Keays Christopher Long*Christopher Long* More articles by this author , Luis BragaLuis Braga More articles by this author , John WienerJohn Wiener More articles by this author , Mark ZaontzMark Zaontz More articles by this author , and Melise KeaysMelise Keays More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000940.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The lack of standardized reporting in hypospadias limits quality improvement and comparative effectiveness research. Variability in surgical decision making and reported complication rates in hypospadias surgery warrants further study to improve care delivery outcomes. Barriers to collaboration include small patient number, single institution efforts, and variability in patient assessment and reporting. Our goal was to create a document that could be shared across institutions, standardizing the documentation process. METHODS: A review of currently existing hypospadias scoring systems, data collection forms from existing registries (INSPIRE, HOLD) and expert opinion identified various datapoints for documentation. Expert feedback was obtained to determine necessary elements for surgical billing, a complete operative note and data elements for hypospadias reporting. Collaboration with an electronic health record (EHR) vendor established reportable data elements. A standardized clinical documentation form was created for preoperative measurements, intra-operative details and post-operative follow-up was created. RESULTS: An EHR standardized document was created for both documentation and research purposes (Figure 1). The operative note includes the type of repair, the planned intervention, type of anesthesia. The initial operative assessment includes the location of the urethral meatus, associated scrotal anomalies, the presence and degree of penile curvature, and the quality of the urethral plate. Specifics for orthoplasty, glansplasty, and urethroplasty are captured. Further granular details such as suture utilization, use of barrier layers, and duration of stent placement amongst others are also included, if the user elects to utilize them. The follow up note includes both functional and cosmetic assessment, reporting complications in a standardized fashion. CONCLUSIONS: This template standardizes the documentation of both intraoperative and follow up patients with hypospadias; it serves the dual purpose of clinical documentation and quality reporting. Furthermore, this will facilitate collaboration across institutions to improve the quality of the urologic literature. We present this work to foster broad utilization across centers. Source of Funding: none © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e979-e980 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Christopher Long* More articles by this author Luis Braga More articles by this author John Wiener More articles by this author Mark Zaontz More articles by this author Melise Keays More articles by this author Expand All Advertisement PDF downloadLoading ...

Preoperative Biliary Stenting and Major Morbidity After Pancreatoduodenectomy: Does Elapsed Time Matter?

To analyze possible associations between the duration of stent placement before surgery and the occurrence and severity of postoperative complications after pancreatoduodenectomy (PD). The effect of preoperative stent duration on postoperative outcomes after PD has not been investigated. From 2013 to 2016, patients who underwent PD for any reasons after biliary stent placement at 5 European academic centers were analyzed from prospectively maintained databases. The primary aim was to investigate the association between the duration of preoperative biliary stenting and postoperative morbidity. Patients were stratified by stent duration into 3 groups: short (<4 weeks), intermediate (4-8 weeks), and long (≥8 weeks). In all, 312 patients were analyzed. The median time from stent placement to surgery was 37 days (2-559 days), and most operations were performed for pancreatic cancer (67.6%). Morbidity and mortality rates were 56.0% and 2.6%, respectively. Patients in the short group (n = 106) experienced a higher rate of major morbidity (43.4% vs 20.0% vs 24.2%; P < 0.001), biliary fistulae (13.2% vs 4.3% vs 5.5%; P = 0.031), and length of hospital stay [16 (10-52) days vs 12 (8-35) days vs 12 (8-43) days; P = 0.025]. A multivariate adjusted model identified the short stent duration as an independent risk factor for major complications (odds ratio 2.64, 95% confidence interval 1.23-5.67, P = 0.013). When jaundice treatment cannot be avoided, delaying surgery up to 1 month after biliary stenting may reduce major morbidity, procedure-related complications, and length of hospital stay.

Clinical Success Stenting Distal Bronchi for "Lobar Salvage" in Bronchial Stenosis.

Airway stents are traditionally used in central airway obstructions to maintain airway patency. Historically, distal bronchial stenting within lobar and segmental bronchi has not been amenable to stenting. In addition, there are questionable benefits to stenting small airways. The Atrium iCast stent is a polytetrafluoroethylene covered stainless steel balloon deployed stent which can be deployed through a flexible bronchoscope under direct visualization. The purpose of this study was to assess the feasibility, complications, and long-term impact of using this stent in patients with lobar bronchial stenosis either secondary to malignancy or benign etiologies. All records of patients who had the placement of an iCast stent were reviewed over 3.5 years. For each patient the age, sex, location, histology, stent size, duration of stent placement, radiographic improvement, and complications were collected. A total of 122 iCast stents were deployed in 38 patients with lobar bronchial stenosis. The average age was 58 years with 50% male. The etiology included 45% malignant and 55% due to benign conditions. In total, 18.5% patients had stents placed in >1 segment. There was an average of 4 procedures per patient with a mean time to stent revision or removal of 85 days. All patients had symptomatic or radiographic improvement. Common complications included migration (10%), granulation tissue formation (5%), deployment malfunction (2%), stent dislodgement immediately after deployment (2%), mucous plugging (1%), and tumor occlusion (1%). Stenting small airways with lobar salvage is feasible and improves symptoms and radiographic outcomes.

Early removal of biflanged metal stents in the management of pancreatic walled-off necrosis: a prospective study.

Dedicated stents placed under endoscopic ultrasound (EUS) guidance have shown promise for the management of pancreatic walled-off necrosis (WON). A long duration of stent placement may increase the risk of adverse events. We prospectively evaluated the effects of (i) early removal of biflanged metal stents (BFMSs) and (ii) additional stenting of the pancreatic duct with plastic stents in patients with ductal leaks, on the risk of WON recurrence. Symptomatic patients with pancreatic WON underwent EUS-guided BFMS placement, followed by necrosectomy, when required, from Day 3. A 5 Fr plastic stent was placed in patients with ductal leak. BFMS was removed when the WON cavity had collapsed completely. Patients were followed up at 3-month intervals. BFMS placement was successful in all 88 patients. A total of 64 patients (72.7 %) underwent necrosectomy (median 3 sessions). All BFMSs were removed at a median of 3.5 weeks (range 3 - 17 weeks). Ductal disconnection and leak occurred in 53/87 (60.9 %) and 61/87 (70.1 %) patients, respectively. A 5 Fr stent was placed in 56/61 patients (91.8 %) with ductal leak. Overall, 22 patients (25.0 %) had adverse events (17 mild, 1 moderate, 3 severe, 1 fatal). Recurrence was noted in 8/88 (9.1 %) at a median follow-up of 22 months. The recurrence rate was higher in patients with ductal disconnection than in those without (13.2 % vs. 2.9 %; P = 0.08), and was similar in patients with vs. without pancreatic duct stenting (7.1 % vs. 12.9 %; P = 0.44). Seven recurrences (87.5 %) partially regressed on follow-up and did not require therapy; in one case, drainage with a plastic stent was performed. Short-term BFMS placement is an effective therapy for pancreatic WON. The majority of recurrences developed in patients with ductal disconnection and did not require therapy. Additional pancreatic duct stents probably do not influence the recurrence rate.

Covered Balloon-Expanding Stents in Airway Stenosis.

The balloon-expanding stents are widely available but rarely described for use within the tracheobronchial tree. This report describes our experience with these stents in airway stenosis particularly as a lobar salvage therapy. This was a retrospective review of all records in which the balloon-expanding stents were used at a tertiary medical center. Ages, sex, location of stenosis, etiology of stenosis, stent size, duration of stent placement and associated interventions for airway stenosis were recorded. Patient's self-reported respiratory symptoms, dyspnea scale, and radiographic imaging at baseline and after stent placement were also reported. Twenty-one Atrium iCAST stents were inserted in 18 patients with malignant and benign airway disease. The median age was 69.5 years (interquartile range, 53.5 to 74). Most stents (n=20, 95%) were deployed in the lobar airways. There was a significant improvement in the modified Medical Research Council dyspnea scale from median of 3 to 2 (P<0.05). Self-reported respiratory symptoms improved in 14 patients (78%, P<0.05). Radiographic improvement post Atrium iCAST stent placement was achieved in 15 patients (83%). No deaths were related to airway stenting complications. Adverse events related to stents included migration (n=2, 9.5%), granulation tissue formation (n=2, 9.5%) and mucus plugging (n=1, 4.8%). Lobar stenting with balloon-expanding metallic stents appears feasible, safe and improves symptoms as well as radiographic atelectasis in patients with lobar airway stenosis in this small case series. Larger studies are needed to confirm this observation and to address long-term safety.

Complications and management of forgotten long-term biliary stents.

AIMTo evaluate complications and management outcomes of retained long-term plastic biliary stents.METHODSEndoscopic plastic biliary stent placement was performed in 802 patients at Yeungnam University Hospital between January 2000 and December 2014. Follow-up loss with a subsequently forgotten stent for more than 12 mo occurred in 38 patients. We retrospectively examined the cause of biliary stent insertion, status of stents, complications associated with biliary stents and management outcomes of long-term plastic biliary stents. Continuous variables were analyzed using the t test. Observed frequencies in subsets of the study population were compared using Fisher’s exact test and χ2 tests. Statistical significance was defined as P < 0.05 (two-tailed).RESULTSMean age of patients was 73.7 ± 12 years and male-to-female ratio was 2.2:1. Indications of plastic biliary stent insertion were bile duct stones (63.2%, 24/38) and benign bile duct stricture (52.6%, 20/38). Mean duration of retained plastic stent was 22.6 ± 12.2 mo, and in 10 cases (26.3%), stents were retained for more than 24 mo. Common bile duct (CBD) stones or sludge were found in most cases (92.1%, 35/38). The most common complication was acute cholangitis (94.7%, 36/38). Stent removal by endoscopic approach was successfully performed in 92.1% (35/38) of the cases. In 3 cases, an additional plastic stent was inserted alongside the previous stent due to failure of the stent removal. Endoscopic removal of bile duct stones was successful in 73.7% (28/38) of the cases. When patients were divided into two groups by duration of stent placement (12 to 24 mo vs over 24 mo), there were no differences in the development of cholangitis, presence of biliary stones, and success rate of endoscopic removal of stones and biliary stents.CONCLUSIONThe most common complication of retained long-term plastic biliary stents was acute cholangitis associated with CBD stones. Endoscopic management was successfully performed in most cases.

Indian Survey on Practice Patterns of Lacrimal and Eyelid Disorders (iSUPPLE) Report 2: Mitomycin-C and Lacrimal Stents in Dacryocystorhinostomy.

The aim of the study was to assess practice patterns on the use of intraoperative Mitomycin-C (MMC) and lacrimal stents (intubation) in dacryocystorhinostomy (DCR) for nasolacrimal duct obstruction (NLDO) among oculoplastic surgeons in India. The survey was aimed at obtaining data on the duration of stent placement and specifics regarding MMC usage namely, concentration and duration of application. A survey that included questions on the management of lacrimal disorders was sent in April 2015 to members of the Oculoplastic Association of India, through an email communication. The results were tabulated and analyzed. External DCR is the preferred surgery of choice to treat NLDO for most oculoplastic surgeons (86%) surveyed. A majority (58%) of the respondents do not place stents during DCR routinely in their practice. Lesser experienced oculoplastic surgeons (<10 years of experience) when compared with more experienced surgeons were more likely to place stents routinely in their DCRs (59% versus 19%; P = 0.0002). Of the special situations that the respondents would consider stent placement, the most common scenarios were the presence of coexisting canalicular pathology followed by cases of previously failed DCRs. The preferred duration for stent removal was 3 months (48%). Intraoperative MMC was used routinely by only 36% of the respondents. The most common condition where they would consider intraoperative MMC was previously failed DCRs. Three minutes (25%) and 0.2 mg/mL (30%) were the preferred duration of application and concentration of MMC, respectively. External DCR is the most preferred surgery for NLDO; in comparison, endoscopic DCR enjoys less popularity as the surgical procedure of choice in NLDO. Adjunctive procedures, namely intraoperative MMC and stenting of the lacrimal passages, are not routinely performed; however, previously failed DCRs are common indications when the respondents may use MMC and/or lacrimal stents. Three months is the preferred duration for stent removal. The trends regarding the concentration of MMC and the application show considerable variation, underscoring the need for evidence-based guidelines to assist oculoplastic surgeons.

Outcome of hypospadias repair - stentless versus stented repair

Background: This study was undertaken to evaluate the outcome of hypospadias repair with or without stents. Methods: Total 30 patients below 14 years underwent primary and re-operative hypospadias surgery in NSCB medical college, Jabalpur between September 2006 to September 2007. Out of these 30 patients, 18 were proximal and 12 were distal hypospadias. All patients were operated for hypospadias repair using standard operative techniques. In alternate patient stent was not placed, while urethral stents were kept in place for a week in the remaining half. Results: In 14 cases early stent removal was done or no stent was placed and in 16 cases late removal of stent was done. In distal hypospadias cases 2 patients developed fistula and both were from the group in which stents were placed .In proximal hypospadias 6 patients developed fistula post operatively, of these 4 were from the early removal group while 2 were from the late stent removal group. The duration of hospital stay was not significantly affected by the duration of stent placement. But doing a MAGPI procedure significantly reduced hospital stays as compared to Snodgrass repair in distal hypospadias. No such difference in hospital stay was associated with different procedures used in proximal hypospadias. Conclusions: Stent placement can be avoided specially in cases of distal hypospadias to reduce morbidity and post-operative stay in these patients. Repair with stents or without stents did not affect the outcome of hypospadias repair in terms of fistula formation or postoperative stay.

Risk Factors for Migration, Fracture, and Dislocation of Pancreatic Stents

Aim. To analyze the risk factors for pancreatic stent migration, dislocation, and fracture in chronic pancreatitis patients with pancreatic strictures. Materials and Methods. Endoscopic stent placements (total 386 times) were performed in 99 chronic pancreatitis patients with pancreatic duct stenosis at our institution between April 2006 and June 2014. We retrospectively examined the frequency of stent migration, dislocation, and fracture and analyzed the patient factors and stent factors. We also investigated the retrieval methods for migrated and fractured stents and their success rates. Results. The frequencies of stent migration, dislocation, and fracture were 1.5% (5/396), 0.8% (3/396), and 1.2% (4/396), respectively. No significant differences in the rates of migration, dislocation, or fracture were noted on the patient factors (etiology, cases undergoing endoscopic pancreatic sphincterotomy, location of pancreatic duct stenosis, existence of pancreatic stone, and approach from the main or minor papilla) and stent factors (duration of stent placement, numbers of stent placements, stent shape, diameter, and length). Stent retrieval was successful in all cases of migration. In cases of fractured stents, retrieval was successful in 2 of 4 cases. Conclusion. Stent migration, fracture, and dislocation are relatively rare, but possible complications. A good understanding of retrieval techniques is necessary.

Endonasal flap suture-dacryocystorhinostomy (eFS-DCR): a new surgical technique for nasolacrimal duct obstruction (NLDO)

Conclusion: Endonasal flap suture-dacryocystorhinostomy (eFS- DCR) is a new and valuable technique for the treatment of nasolacrimal duct obstruction (NLDO). This technique could improve the success rate of endonasal DCR in comparison to external DCR. Objective: The standard procedure for NLDO is DCR. DCR can be performed via either an external or endonasal approach. External DCR is now regarded as the gold standard in the treatment of NLDO because of its higher success rate. However, we report a new endonasal surgical technique, eFS-DCR, and assess its efficacy by comparison with the standard endonasal DCR. Methods: We prospectively investigated a series of 62 consecutive patients with NLDO undergoing endonasal DCR. There were two surgical intervention groups: group 1 (24 patients, 28 sites) undergoing endonasal DCR without eFS; and group 2 (38 patients, 47 sites) undergoing eFS-DCR. Study end points were success rate, the ostium diameter (OD) of the lacrimal sac after DCR, and the duration of stent placement. We compared the two groups on these three points. Results: The success rate was 78.6% (22 of 28 sites) for group 1 (DCR without eFS) and 97.9% (46 of 47 sites) for group 2 (eFS-DCR). The ostium size in patients in group 2 was larger than that in group 1. The median time for the duration of stent placement was 42.5 days for group 1 and 31.5 days for group 2. There was a statistical difference (p < 0.01) in all these parameters between the two groups.

Ureteral Stent May Not Be Associated With The Development of Significant BK Viruria and/or Viremia.

Background: In recent years, the incidence of Polyoma BK virus infection has increased in renal transplant recipients. Several risk factors have been proposed including intensity of immunosuppression, higher HLA mismatch, pediatric status, BK virus mismatch between donor and recipient, immunosuppressant drugs, and most recently ureteral stent placement. Some studies have suggested a potential role of ureteral trauma in the pathogenesis of BK virus infection. No studies have found an association of ureteral stent duration with significant BK viruria (BKU), BK viremia (BKV), or BK nephropathy (BKN). Objective: We aimed to determine if ureteral stent placement is an independent risk factor for BK virus infection and to evaluate different risk factors for BKU and BKV adjusted for presence or absence and duration of stent placement. Methods: 93 consecutive kidney transplant recipients treated by 2 surgeons during Sep 2010 to July 2012 followed for more than 1 year were included in this analysis. Multiple variables including blood type, donor type, race, gender, induction regimen, DM status, and presence of ureteral stent were evaluated. All patients had documented negative BK virus in urine and blood before transplantation. Maintenance immunosuppression consisting of tacrolimus, mycophenolate sodium and corticosteroids were used in all patients. Results: Surgeon A who does not place an ureteral stent performed 48 (52%) cases and Surgeon B who routinely places an ureteral stent performed 45 (48%) cases. Basiliximab induction was used in 66 patients (71%) and rabbit anti-thymocyte globulin in 27 patients (29%). The stent was removed at a median (minimum-maximum) time of 94 (9-964) days from the transplant. The overall incidence of BKU and BKV was 42.2% and 26.8% of tested patients respectively. A significant difference was detected between those with and without BKU in race distribution, with more Hispanics (p=0.041) in the positive BKU group. There was also a significant association with male gender and BKV (p=0.03). There was no significant difference between subjects with and without ureteral stent placement in BKU (p= 0.72) or BKV (p= 0.97), or for duration of stent in BKU (p= 0.56) or BKV (p= 0.85). Conclusions: Our study would suggest that placement of ureteral stent in and of itself would not confer additional risk for BK virus infection.

Risk factors for proximal migration of biliary tube stents

To analyze the risk factors for biliary stent migration in patients with benign and malignant strictures. Endoscopic stent placement was performed in 396 patients with bile duct stenosis, at our institution, between June 2003 and March 2009. The indications for bile duct stent implantation included common bile duct stone in 190 patients, malignant lesions in 112, chronic pancreatitis in 62, autoimmune pancreatitis in 14, trauma in eight, surgical complications in six, and primary sclerosing cholangitis (PSC) in four. We retrospectively examined the frequency of stent migration, and analyzed the patient factors (disease, whether endoscopic sphincterotomy was performed, location of bile duct stenosis and diameter of the bile duct) and stent characteristics (duration of stent placement, stent type, diameter and length). Moreover, we investigated retrieval methods for migrated stents and their associated success rates. The frequency of tube stent migration in the total patient population was 3.5%. The cases in which tube stent migration occurred included those with common bile duct stones (3/190; 1.6%), malignant lesions (2/112; 1.8%), chronic pancreatitis (4/62; 6.5%), autoimmune pancreatitis (2/14; 14.3%), trauma (1/8; 12.5%), surgical complications (2/6; 33.3%), and PSC (0/4; 0%). The potential risk factors for migration included bile duct stenosis secondary to benign disease such as chronic pancreatitis and autoimmune pancreatitis (P = 0.030); stenosis of the lower bile duct (P = 0.031); bile duct diameter > 10 mm (P = 0.023); duration of stent placement > 1 mo (P = 0.007); use of straight-type stents (P < 0.001); and 10-Fr sized stents (P < 0.001). Retrieval of the migrated stents was successful in all cases. The grasping technique, using a basket or snare, was effective for pig-tailed or thin and straight stents, whereas the guidewire cannulation technique was effective for thick and straight stents. Migration of tube stents within the bile duct is rare but possible, and it is important to determine the risk factors involved in stent migration.

Endoscopic stenting for benign upper gastrointestinal strictures and leaks

Self-expandable metal stents (SEMS) and self-expandable plastic stents (SEPS) maybe used for the treatment of benign upper gastrointestinal (GI) leaks and strictures. This study reviewed our experience with stent insertions in patients with benign upper GI conditions. Patients who underwent stent placement for benign upper GI strictures and leaks between March 2007 and April 2011 at a tertiary referral academic center were studied using an endoscopic database and electronic patient records. The technical success, complications, and clinical improvement after stent removal were compared according to type of stent. The outcomes measured were clinical response, adverse events, and predictors of stent migration. Thirty-eight patients (50 % male, mean age = 54 years, range = 12-82) underwent 121 endoscopic procedures. Twenty patients had stents placed for strictures, and 18 had stents placed for leaks. Stent placement was technically successful in all patients. The average duration of stent placement was 54 days (range = 18-118). Clinical improvement immediately after stent placement was seen in 29 of the 38 patients (76.3 %). Immediate post-procedure adverse events occurred in 8 patients. Late adverse events were seen in 18 patients. Evidence of stent migration occurred in 16 patients and was seen in 42 of the 118 successfully placed stents (35.5 %). Migration was more frequent with fully covered SEMS (p = 0.002). After stent removal, 27 patients were evaluable for long-term success (median follow-up time of 283 days, IQR 38-762). Resolution of strictures or leaks was seen in 11 patients (40.7 %). Predictors for long-term success included increasing age and if the stent did not cross the GE junction. Placement of SEPS and SEMS for benign refractory strictures and fistulas has modest long-term clinical efficacy and is limited by a significant migration rate. Stent migration is common and frequent with fully covered SEMS compared to other types of stents, regardless of indication or location.

Abstract No. 338 - Outcome of catheter size and duration of internal-external biliary drainage on stricture recurrence of benign biliary strictures

Purpose Determine if tube size or duration of internal-external biliary drainage are important factors in the length of time benign biliary strictures can be treated without surgery or the rate of stricture recurrence after successful treatment. Materials and Methods From August 9 1996 - August 31 2009, 63 patients underwent percutaneous transhepatic biliary drainage (PTBD) of benign biliary strictures with small caliber drains (8-14F). Clinical and demographic factors, catheter size, duration of stent placement and duration of stricture patency after drain removal were reviewed. Success was defined as stricture patency of greater than 1 year after stent removal. Failure was defined as replacement of stent after removal, death during stenting, surgery during stenting and retention of stent without resolution of symptoms. Multivariable logistic regression and cox proportional harzard were performed. Results Median follow-up from stent placement was 1027 days (Range (R) 13-5184) and after stent removal was 753 days (R 14-2943). Median stent duration was 193 days (R 0-4380). 20 patients (31.7%) were stricture recurrence-free for greater than 1 year after stent removal with a median stricture recurrence-free period of 946 days. The presence of stricture after choledocojejunostomy (CJ) or hepaticojejunostomy (HJ) was predictive of stricture recurrence-free outcome (p Conclusion In this small sample of patients with benign biliary strictures, PTBD of CJ/HJ strictures is associated with a better outcome independent of catheter size. Table 1