Early Stent Research Articles

Early precut is as efficient as pancreatic stent in preventing post-ERCP pancreatitis in high-risk subjects - A randomized study.

The most common adverse event of endoscopic retrograde cholangiopancreatography is pancreatitis. Precut sphincterotomy has been regarded as a risk factor. Some authors have stated that early precut may actually reduce post-ERCP pancreatitis risk. However, early precut as a preventive measure has not been compared to other preventive measures, such as pancreatic duct stent placement. To compare the efficacy of early precut sphincterotomy versus pancreatic duct stent placement in high-risk subjects undergoing endoscopic retrograde cholangiopancreatography for the prevention of post-endoscopic cholangiopancreatography. This was a single-blinded, randomized trial that took place in two tertiary referral centers in Buenos Aires, from November 2011 to December 2013. ERCP subjects presented at least one of the following risk factors: female sex, age less than 40 years, clinical suspicion of sphincter of Oddi dysfunction, previous pancreatitis, and/or common bile duct diameter of less than 8 mm. Only those who presented a difficult biliary cannulation were randomized into two groups: those who received early precut sphincterotomy and those in whom persistency of biliary cannulation was intended, with subsequent pancreatic duct stent placement after cholangiography was achieved. The incidence of post-ERCP pancreatitis, as well as other adverse events incidence, was compared. Overall, 101 patients were enrolled, 51 in the pancreatic duct stent group and 50 in the early precut group. Pancreatitis rate was similar in both groups (3.92% vs 4%, p NS). In all cases, pancreatitis was classified as mild. There were no deaths registered. Early precut was associated with an incidence of adverse events similar to pancreatic duct stent placement.

Complication Rate of Palliative Colonic Stenting for Metastatic Colorectal Cancer

Introduction: Some patient with metastatic colorectal cancer present colonic obstruction by their primary tumor. Palliative colonic stenting is associated with risks of colonic perforation, death and risk is probably increased with anti-VEGF. We reviewed our procedures and complications to confirm benefit with acceptable risks in our local population. Methods: We reviewed the files of all patients with colonic stenting with self-expandable metal stent (SEMS) between January 2005 and March 2014. Stenting of benign stenosis or bridge to surgery were excluded. Results: Colonic stents were used as palliation in 128 patients; 127 had metastatic colorectal cancer and 1 had locally advanced non-resectable sigmoid cancer. Our population comprise 89 women and 39 men (70|30%) with mean age of 76 (43 to 93 year-old). 31 (24%) patients were on chemotherapy before the procedure. Bevacizumab was utilised in a total of 8 patients.The procedure was considered technically successful in 120 (94%). Early major complications (≤ 7 days) were stent dysfunction 1/120, stent migration 3/120 and perforation 4/120. Within those, 3 patients recovered with medical treatment and, one developed overt haemorrhage and died in the week following urgent hemicolectomy. The one patient with early stent dysfunction had balloon dilatation and perforation ensued. The three patients with early stent migration had balloon dilation and deployment of a second stent, colonic perforation was recorded in all three with subsequent death. Total early complication rate was 7% (8/120) and early death rate was 4% (5/128). Reported late complications (> 7 days) were stent dysfunction 13/120 (11%) and no migration or perforation occurred. The perforation risk associated with stricture dilatation was 44% (4 early perforations in 9 balloon dilatations, all were fatal). The perforation rate with anti-VEGF was 63% (5 perforations in 8 patients on anti-VEGF) with 50% mortality (4/8). The perforation in anti-VEGF plus balloon dilatation is 100%(4/4) and is always fatal. Conclusion: The early major complication rate is 7% with a 4% death. The perforation and mortality of stent installation are marked in the group of bevacizumab, with balloon dilation and when these two factors were associated; with a 100% perforation and mortality. This outlines the importance of patient selection and appropriate intervention for optimal quality of care.

Coronary Stents: The Impact of Technological Advances on Clinical Outcomes.

Percutaneous coronary interventions (PCI) were proposed in the late 1970s as an alternative to surgical coronary artery bypass grafting for the treatment of coronary artery disease. Important technological progress has been made since. Balloon angioplasty was replaced by bare metal stents, which allowed to permanently scaffold the coronary vessel avoiding acute recoil and abrupt occlusion. Thereafter, the introduction of early generation drug-eluting stents (DES) has significantly improved clinical outcomes, primarily by markedly reducing the risk of restenosis. New generation DES with thinner stent struts, novel durable or biodegradable polymer coatings, and new limus antiproliferative agents, have further improved upon the safety and efficacy profile of early generation DES. The present article aims to review the impact of technological advances on clinical outcomes in the field of PCI with coronary stents, and to provide a brief overview on clinical margins of improvement and unmet needs of available DES.

Use of tracheal stenting in the palliation of anaplastic thyroid carcinoma: tertiary centre experience.

Anaplastic thyroid carcinoma is rare but carries a poor prognosis. Anaplastic thyroid carcinoma leads to tracheal compression, airway compromise and eventually death. Airway compromise, a particularly distressing symptom, can be palliated with tracheal stenting. A retrospective case note analysis was conducted of patients diagnosed with anaplastic thyroid carcinoma between July 2003 and July 2013. Twelve patients with anaplastic thyroid carcinoma were identified. Four patients underwent palliative tracheal stenting. Three patients had no dyspnoea at the time of stenting. Two stented patients subsequently developed dyspnoea secondary to stent migration; this was managed successfully with stent exchange. The other stented patient remained asymptomatic with regards to dyspnoea. All non-stented patients died with or from airway compromise. Tracheal stenting is a relatively safe and effective method for palliation of distressing airway symptoms in patients with anaplastic thyroid carcinoma. Early prophylactic tracheal stenting in anaplastic thyroid carcinoma may be an effective option to prevent development of airway compromise as the disease progresses.

Treatment of oesophageal perforations and its complications (Mediastinitis, abscess) with covered metal stent and drainage

Introduction: The covered metal stents were first used for malignant oesophageal stenosis. Since 2007 we have used it 15 times for treatment of oesophageal perforations and post-operative leaks. Methods and patients: When the perforation or leakage was recognised the decision on the ways of therapy was done after consultation with an oesophageal surgeon. The optimal size of retrievable covered metal stent was calculated individually. The stenting was supplemented in most cases with drainage, and with antibiotic treatment in an intensive care unit. The timing of stent removal (in most cases 6 – 10 weeks) was after individual consideration. The indications for stenting were: iatrogenic perforation in corrosive stenosis in 4 cases; Boerhaave's syndrome in 2 cases; postoperative leakage in 6 cases; oesophagus defect after thyroid surgery in 1 case and thoracic empyema with oesophageal fistula in 2 cases. Results: The oesophageal defect was sailed in all 15 cases. One patient died as a result of a non-related disease – severe lung destruction and aspergillosis. Twelve oesophagus defects were healed from 14 patients. In one case, with operated Boerhaave's syndrome, the inveterate fistula persisted. In another case, the septic patient with Boerhaave's syndrome was treated with drains and late stenting. After medical stabilization two (residual) mediastinal abscesses were left; they were not drained by the referring hospital despite our request. After removing the stent we observed 2 fistulae. After subtotal oesophagectomy substernal a gastric tube bypass was performed. Conclusion: Early stenting and drainage is a safe, effective and less invasive treatment of oesophageal perforation and leakage with low mortality.

Treatment of hypertension in patients with coronary artery disease: A scientific statement from the American Heart Association, American College of Cardiology, and American Society of Hypertension

Neutrophil gelatinase associated lipocalin (NGAL) and matrix metalloproteinase (MMP)-9/NGAL complex were investigated in asymptomatic patients with carotid artery stenosis including gender specific differences aiming at vulnerable plaques prone to embolisation.Serum NGAL and MMP-9/NGAL levels were analysed in 83 patients with asymptomatic carotid artery stenosis. Pre-operative ultrasound and post-endarterectomy histology of carotid atherosclerotic lesions were evaluated.Patients with vulnerable plaques, as determined by ultrasound (plaques with decreased echogenicity) and histological analysis (type VI according to the classification of the American Heart Association), displayed the highest levels of NGAL and MMP-9/NGAL complex (p = .0003 and p = .0078, respectively). Grade VI plaques were primarily detected in patients with “soft” plaques (12 type VI plaques in 25 patients), but also in patients with mixed (four of 19) and calcified (three of 39) plaques according to ultrasound. Higher grade carotid artery stenosis (≥90%) was not associated with elevated NGAL levels. The receiver operating characteristic curve analysis detecting grade VI lesions yields an area under the curve (AUC) = 0.85, with respect to soft plaque on ultrasound the AUC = 0.86. There were no gender specific differences in levels of NGAL 80.9 (37.7) ng/mL in women vs. 76.7 (36.3) ng/mL in men, p = .607) nor of MMP-9/NGAL 33.0 (18.2–55.5) ng/mL in women vs. 36.7 (20.2–54.0) ng/mL in men, p = .969. Likewise, there were no gender associated differences in vulnerable plaque characteristics: either for grade VI plaques (17.9% vs. 27.3%, p = .582) or for the presence of soft plaques as evaluated by ultrasound (35.9% vs. 25%, p = .503).Circulating NGAL and MMP-9/NGAL are significantly increased in asymptomatic patients with vulnerable carotid atherosclerotic plaques independent of gender. Accordingly, serum NGAL may be proposed as a valuable biomarker for the detection of unstable carotid plaques in asymptomatic patients, who can then be selected for early carotid endarterectomy or stenting.

Comparison of Short- and Long-Term Cardiac Mortality in Early Versus Late Stent Thrombosis (from Pooled PROTECT Trials)

Studies have indicated varying mortality risks with timing of stent thrombosis (ST), but few have been adequately powered with prospective late follow-up. PROTECT randomized 8,709 subjects to either Endeavor zotarolimus-eluting or Cypher sirolimus-eluting stents. PROTECT Continued Access enrolled 1,018 patients treated with Endeavor zotarolimus-eluting stents. Subjects completed at least 4 and 3years of follow-up, respectively. ARC-defined definite and probable ST events were stratified by time from index procedure: early (≤30days), late (>30 and ≤360days), and very late (>360days). Rates of death and myocardial infarction were analyzed by ST timing. Median follow-up was 4.1years. There were 184 ST events (1.9%): 61 early, 27 late, and 96 very late. Patient and procedural characteristics were similar between timing groups. There was no difference in dual-antiplatelet therapy use at discharge (97%) or 1year (84%). Cardiac death in patients with ST at 4years occurred in 32.1% compared with 2.5% in patients without ST (p <0.001). Combined rates of cardiac death and myocardial infarction did not differ according to ST timing, yet early ST was more commonly associated with cardiac death at 4years than later ST (50.8% for early vs 18.5% for late vs 24.0% for very late; p <0.001). The relation between ST timing and outcomes did not differ between stent types. In conclusion, in prospective data, cardiac death was more common after early ST than later ST. Although ST remains infrequent, continued efforts to determine how to reduce ST, particularly within the first 30days, are warranted. (The PROTECT trial is registered with ClinicalTrials.gov, number NCT00476957.).

Continuing Medical Education Exam: April 2015

Instructions: The GIE: Gastroinintestinal Endoscopy CME Activity can now be completed entirely online. To complete do the following: 1. Read the CME articles in this issue carefully and complete the activity: Holt BA, Jayasekeran V, Williams SJ, et al. Early metal stent insertion fails to prevent stricturing after single-stage complete Barrett’s excision for high-grade dysplasia and early cancer. Gastrointest Endosc 2015;81:857-64. Abougergi MS, Travis AC, Saltzman JR. The in-hospital mortality rate for upper GI hemorrhage has decreased over 2 decades in the United States: a nationwide analysis. Gastrointest Endosc 2015;81:882-8. Schlag C, Menzel C, Nennstiel S, et al. Emergency video capsule endoscopy in patients with acute severe GI bleeding and negative upper endoscopy results. Gastrointest Endosc 2015;81:889-95. Dhir V, Itoi T, Khashab MA, et al. Multicenter comparative evaluation of endoscopic placement of expandable metal stents for malignant distal common bile duct obstruction by ERCP or EUS-guided approach. Gastrointest Endosc 2015;81:913-23. 2. Log in online to complete a single examination with multiple choice questions followed by a brief post-test evaluation. Visit the Journal’s Web site at www.asge.org (members) or www.giejournal.org (nonmembers). 3. Persons scoring greater than or equal to 75% pass the examination and can print a CME certificate. Persons scoring less than 75% cannot print a CME certificate; however, they can retake the exam. Exams can be saved to be accessed at a later date. You may create a free personal account to save and return to your work in progress, as well as save and track your completed activities so that you may print a certificate at any time. The complete articles, detailed instructions for completion, as well as past Journal CME activities can also be found at this site.

Long-term follow-up of the viability guided angioplasty after acute myocardial infarction (VIAMI) trial

BackgroundPatients with ST-elevation myocardial infarction (STEMI) not treated with primary or rescue percutaneous coronary intervention (PCI) are at risk for recurrent ischemia. In non-high risk patients, with proven viability in the infarct-area, the VIAMI trial showed benefit of early in-hospital stenting of the infarct-related coronary artery for the composite of death, myocardial infarction (MI), or unstable angina (UA) at 1year follow-up. In this study we evaluated the long-term outcome (median 8years) of patients included in the VIAMI-trial. MethodsAfter being stable during the first 48h of their acute MI, we randomly assigned 216 patients with viability to an invasive (PCI) or a conservative (ischemia-guided) strategy. The primary outcome was the composite endpoint of death from any cause, recurrent myocardial infarction, or unstable angina. The secondary outcome of this study was the need for (repeat) revascularization. ResultsThe combined endpoint of death, recurrent MI and UA was 20.8% in the invasive group and 32.7% in the conservative group (hazard ratio 0.59; 95% CI 0.36–0.99, p=0.049). No differences were seen in death (8.5% vs. 8.2%, p=0.80) or MI (7.5% vs. 10.9%, p=0.48). Only UA showed a significant difference (4.7% vs. 13.6%, p=0.002). Repeated revascularization was performed in 22.6% of the invasive group and 41.8% of the conservative group (hazard ratio 0.43; 95% CI 0.29–0.74, p<0.001).` ConclusionIn patients with acute MI (treated with thrombolysis or without reperfusion therapy) and proven viability in the infarct-area, we demonstrated a long-term benefit of early in-hospital stenting of the infarct-related coronary artery.

Effect of clinical factors and gene polymorphism of CYP2C19*2, *17 and CYP4F2*3 on early stent thrombosis.

To determine the main clinical and genetic factors having impact on early coronary stent thrombosis. Genotyping of CYP2C19*2, *17 and CYP4F2*3 in patients with (n = 31) and without stent thrombosis (n = 456) was performed. Clinical and genetic data were analyzed by binary logistic regression. Smoking (OR: 0.317; 95% CI: 0.131-0.767), high-density lipoprotein level in mmol/l (OR: 0.142; 95% CI: 0.040-0.506), CYP2C19*2*2 versus *1*1 and *1*2 genotype (OR: 11.625; 95% CI: 3.498-38.633), CYP4F2 AA versus GA and GG genotype (OR: 3.532; 95% CI: 1.153-10.822) were associated with early stent thrombosis. For the first time we have identified a clinically important polymorphism (CYP4F2 G1347A) that was independently associated with early stent thrombosis. Original submitted 18 August 2014; Revision submitted 10 November 2014.

Effectiveness of Endoscopic Management Using Self-Expandable Metal Stents in a Large Cohort of Patients with Post-bariatric Leaks.

Endoscopic management of post-bariatric surgery leaks using self-expandable metal stents (SEMSs) is an alternative to revisional surgery. We evaluated the effectiveness of a standardized protocol for management of post-bariatric surgery leaks in a large cohort of patients. Data from patients with anastomotic leaks after bariatric surgery endoscopically treated with partially covered SEMS in our institution between January 2006 and December 2012 were retrospectively reviewed. Patients were divided into four categories: (1) healing of fistula after only one SEMS, (2) healing of fistula after multiple SEMSs and/or additional therapy, (3) healing of fistula after salvage endoscopic procedure despite SEMS failure, and (4) SEMS and endoscopic failure for fistula healing. Ninety-one patients (median age 42 years; 33 males) were considered suitable for inclusion. Our standardized stenting policy was successful in 74 patients (81 %). Among the 17 patients with SEMS failure, 6 patients were ultimately healed by internal drainage of the leakage (7 %). Endoscopic treatment failed in 11 patients (12 %). In univariate analysis, male gender (p = 0.024), higher prebariatric surgery BMI (p = 0.025), and shorter delay between surgery and SEMS placement (p = 0.011) were more frequently observed in the one-step treatment group (group 1) as compared to the other groups. In multivariate analysis, gender (p = 0.035) and delay between surgery and SEMS placement (p = 0.042) were independent predictive factors of endoscopic success. Endoscopic management using SEMS for anastomotic leaks after bariatric surgery is effective and may avoid risky surgical reintervention in 81 % of patients. Early stenting was a major significant factor associated with increased success.

Early surgical bypass versus endoscopic stent placement in pancreatic cancer.

391 Background: Biliary obstruction frequently occurs in locally advanced or metastatic pancreatic cancer and is often managed by surgical biliary bypass or endoscopic stenting. We compared readmissions/reinterventions among pancreatic cancer patients undergoing bypass vs. stenting. Methods: Retrospective analysis of unresected pancreatic cancer patients in the Healthcare Cost and Utilization Project (HCUP) Florida State Inpatient Database and Florida State Ambulatory Surgery Database 2007-2011 using revisit variables. Patients with early surgical or endoscopic approach analyzed. Subsequent admissions and surgical, endoscopic or percutaneous interventions identified. Propensity score matching by approach. Univariate analysis of patient characteristics and outcomes before and after matching. Multivariate analysis of readmission and reintervention performed by logistic regression. Results: 1,823 and 342 underwent endoscopic treatment vs. early surgical bypass, respectively. After propensity score matching, 684 patients analyzed (table). 64.0% (219) of endoscopic and 70.5% (241) of surgical patients readmitted (p=0.07) and 15.2% (57) and 9.1% (31) underwent reintervention (p=0.01). Endoscopic patients had lower index median length of stay (6 vs 11 days, p&lt;0.01) and admission costs ($11,549 vs $23,215, p&lt;0.01). In multivariate analysis, surgical biliary bypass was predictive of readmission (OR 1.50; 95% CI 1.03-2.18), but initial procedure was not predictive of reintervention (p=0.20). Conclusions: Surgical biliary bypass is less commonly performed than endoscopic stenting. Among propensity score-matched patients, readmission rates are similar, though endoscopic patients require more subsequent interventions. Candidates for both techniques may experience fewer invasive procedures if offered initial surgical biliary bypass. [Table: see text]

Early versus late ureteric stent removal after kidney transplantation

Early versus late ureteric stent removal after kidney transplantation

Acute Caustic Ingestion: State of Art and New Trends

The ingestion of caustic substances, both accidental and voluntary, determines a complex syndrome, characterized by severe, often irreversible, visceral lesions, with still remarkable mortality in highly compromised patients. The most severe esophageal and gastric damage is notoriously related to voluntary and pseudo-voluntary ingestion of high amount or concentration of strong acids or alkali compounds. More recently “liquitabs”, although not always strictly belonging to the caustic category, have been recognized to cause serious damage to the oral cavity and esophagus by rapid osmotic dehydration. Today the ideal approach to caustic ingestion, especially in case of medium or severe damage, should be achieved through the close cooperation of a multidisciplinary team: emergency physician, anaesthetist, toxicologist, endoscopist and surgeon. After the first evaluation of symptoms and clinical signs, the toxicologic assessment and the radiological evaluation, upper digestive endoscopy represents the mainstay of the diagnostic and therapeutic strategy. Despite clinical symptoms, endoscopy is mandatory in all voluntary and pseudo-voluntary ingestions. Endoscopic description of the lesions must be very accurate and possibly referred to an international well known endoscopic classification. Pictures or videos should be encouraged. After endoscopy, eventually including EUS, the team has to decide about the need to perform surgery (laparotomy or thoraco-laparoscopy) or to establish a conservative therapy. In doubtful cases endoscopy can also be short term repeated, under anaestesiological control. Steroid treatment, at least in the majority of cases, is unpredictable and so that kind of therapy should not be in general encouraged, unless in infants and toddlers where high and early dosage of corticosteroids could play a justified role. Early endoscopic esophageal stenting by removable SEMS, or better by biodegradable stents, could play a interesting role in well identified patients.

Feasibility and safety of bilateral same-session flexible ureteroscopy (FURS) for renal and ureteral stone disease.

IntroductionWith rising incidence of urolithiasis, treatment of stones (both symptomatic and asymptomatic) in multiple locations including bilateral stones can be controversial and challenging. We report our experience and treatment outcomes in patients undergoing bilateral, same-session ureterorenoscopy (BS-URS) for bilateral ureteric and/or renal calculi, and discuss the advantages and disadvantages of such procedures.Material and methodsBetween May 2012 and October 2013, 251 patients underwent ureteroscopic surgery for stone disease at our institution. Of these, 21 patients underwent 25 bilateral same-session ureterorenoscopy (BS-URS) procedures during this period. Stone-free status was defined as endoscopically stone-free or radiological fragments <2 mm.ResultsThe mean bilateral stone size was 21mm (range: 4-63 mm) with a mean operating time of 70 minutes (range 35-129 minutes). Fifteen procedures (60%) were done as day case procedures with a mean stay of 0.9 days (range 0-7 days). Of the 42 renal units treated, 80% (34/42) were stone-free after a single bilateral ureteroscopy session. A further 12% (5/42) were cleared after a re-look procedure making the overall stone free rate 92.8% (39/42). There were no major complications and 3 minor complications (2 early stent removals due to stent symptoms and 1 pyelonephritis requiring intravenous antibiotics).ConclusionsBilateral same-session ureteroscopy is a safe and effective treatment option for patients with bilateral ureteric and/or renal calculi, even with stones in multiple locations and increasing stone loads. However, as with all surgery, proper patient and equipment selection is crucial in terms of reducing complication rates and improving treatment outcomes.

Abstract 11019: Incidence and Predictors for Late Acquired Stent Malapposition of Drug-Eluting-Stents With Second-Generation Permanent and Biodegradable Polymer-Coatings - A Prospective, Randomized Comparison Using Optical Coherence Tomography

Introduction: The polymers releasing the drug of first-generation drug-eluting stents (DES) may induce allergic reactions and inflammation, resulting in late-acquired stent malapposition (LASM) with uncoverage of struts, and risk of stent thrombosis. The incidence and predictors of LASM in DES with different polymers designed to improve biocompatibility are unknown. Methods: Fifty patients with 59 lesions of interest were randomized to elective treatment with Everolimus-eluting stents (EES; n=17, 20 lesions)], Zotarolimus-eluting stents (ZES; n=15, 19 lesions), and Biolimus-eluting stents (BES; n=18, 20 lesions) and underwent optical coherence tomography after implantation and after one year. Results: After implantation 29 early stent malappositions (ESM) were documented in 29 lesions (49% of lesions), distributed to 11 lesions treated with EES (55%), 11 with ZES (58%), and 7 with BES (35%; n.s.). After one year 14 late stent malappositions (LSM) in 14 lesions (24%) were detected; nine ESM persisted (EPSM) after one year (1 EES, 6 ZES, 2 BES), whereas 20 ESM resolved. In addition, 9 LASM were documented (5 LASM in early well-apposed Stents, 4 LASM in Stents which also have EPSM). LASM was present in 7 hydrophilic polymer-coated ZESs (37%), in 2 fluoropolymer-coated EESs (10%), and in none of the biodegradable polymer-coated BESs (p=0.003). Independent predictors of LASM were the vessel treated (RCA as vessel with high motion; p&lt;0.022) and type of polymer (biodegradable or permanent; p&lt;0.035). Conclusion: The incidence of ESM and EPSM were similar, whereas the incidence of LASM was different in second-generation DES with different polymers. Biodegradable polymer prevented LASM, stent locations with significant vessel movement (RCA) enhanced LASM.

Early metal stent insertion fails to prevent stricturing after single-stage complete Barrett's excision for high-grade dysplasia and early cancer

Barrett's esophagus with high-grade dysplasia (HGD) or intramucosal adenocarcinoma (IMC) can be effectively treated by single-session EMR, resulting in complete Barrett's excision (CBE). CBE provides accurate histology for staging and clinical confirmation of neoplasia eradication but is limited by a high risk of esophageal stricture formation. To evaluate the effectiveness of prophylactic temporary esophageal stenting to prevent post-CBE stricture formation. Single-center, investigator-initiated feasibility study. Circumferential, short-segment Barrett's esophagus (≤C3≤M5) with HGD or IMC. Single-stage CBE and insertion of a fully covered metal esophageal stent at 10 days that was removed at 8 weeks. Patients were followed for a minimum of 2 surveillance endoscopies. Symptomatic esophageal stricture formation. At the end of the follow-up period, 8 patients (57.1%) required esophageal dilation for symptomatic CBE-related (n= 7) or stent-related (n= 4) strictures. A median of 3 surveillance endoscopies were performed over a median endoscopic follow-up of 17 months (range 4-25 months). Single-stage CBE successfully eliminated Barrett's intestinal metaplasia and neoplasia in 71.4% and 92.9% of patients, respectively. Four patients were admitted to the hospital, and 4 patients had early stent removal because of pain or dysphagia. Single-center feasibility study. In a prospective study evaluating prophylactic esophageal stent insertion after single-stage CBE, esophageal strictures formed in more than of half the study cohort, and stents were associated with significant morbidity. An alternative method to reduce stricture formation is required. ( NCT01554280.).

One-year outcome from an all-comers population of patients with ST-segment elevation myocardial infarction treated with biolimus-eluting stent with biodegradable polymer.

To evaluate the performance of biolimus-eluting stent (BES) in patients with ST-elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI) in a real world clinical scenario. Randomized studies suggest that the BES with biodegradable polymer is more effective and safe than early generation coronary stents in patients with STEMI. We included all consecutive STEMI patients undergoing PCI in this prospective, multicenter registry. The primary endpoint of the study was the rate of major adverse cardiac events (MACE), a composite of cardiac death, recurrent myocardial infarction and ischemia-driven target vessel revascularization at 1-year follow-up. Between June and December 2012 we enrolled 311 STEMI patients. The primary endpoint occurred in 3.2% (95% confidence interval: 1.6-5.8) of patients: cardiac death, re-infarction, and ischemia-driven TVR occurred in 2.3%, 1.3%, and 0.6% of patients, respectively. One-year MACE-free survival was 96.8% ± 1.0%. In a real-world cohort of STEMI patients undergoing PCI, the use of BES is associated with good 1-year clinical outcome. These results confirm and expand previous findings showing the efficacy and safety of BES in the setting of randomized trials.

Revascularisation versus medical treatment in patients with stable coronary artery disease: network meta-analysis

Objective To investigate whether revascularisation improves prognosis compared with medical treatment among patients with stable coronary artery disease.Design Bayesian network meta-analyses to combine direct within trial comparisons between treatments with...

Gastric sleeve leak: a single institution’s experience with early combined laparoendoscopic management

BackgroundSleeve gastrectomy is an effective weight loss procedure that is technically less complex than Roux-en-Y gastric bypass. However, staple line leak (SLL) remains a significant complication of this procedure with reported incidence ranging from 1%–7%. Multiple treatment strategies for SLL are reported including surgical re-exploration, percutaneous drainage, and endoscopic stenting. Our objective was to review the results of our experience with combined laparoendoscopic procedures in managing SLL. MethodsA retrospective review of patients with SLL after laparoscopic sleeve gastrectomy (LSG) between June 2008 and October 2013 was performed. Patient characteristics, operative details, and postoperative management strategies were reviewed. All patients were managed with a combination of early laparoscopic washout and endoscopic stenting. ResultsOne hundred sixty-five patients underwent LSG with SLL identified in 4 patients (2.4%). One patient was transferred from an outside institution for SLL. Average time to SLL diagnosis was postoperative day 3 (range 1–7). After diagnosis patients underwent laparoscopic washout and initial endoscopic stenting. Three patients required additional endoscopic procedures to manage stent migration, and 2 required additional procedures for peri-stent leak. Complications were managed endoscopically with stent adjustment or replacement. Patients had indwelling stents for an average of 29 days (range 15–56). Mean hospital length of stay was 30 days (range 20–42). ConclusionSLL after LSG can confer a high morbidity and mortality. Endoscopic management of SLL with stenting has been advocated because it successfully manages the leaks and avoids additional invasive procedures. Based on our experience, successful management of SLL can be achieved with an early combined laparoendoscopic approach.