Endoscopic Stent Placement Research Articles

Endoscopic transpapillary pancreatic duct stent placement in patients with necrotizing pancreatitis

Aim . Improvement of treatment results in patients with necrotizing pancreatitis and signs of the dissociation between the distal and proximal parts of the pancreas by using endoscopic transpapillary stent placement. Material and methods . There were 25 patients with acute necrotizing pancreatitis and disconnected pancreatic duct syndrome, which have been managed by using endoscopic transpapillary stent placement throughout 2018-2020. Twenty patients have been admitted into hospital in first 24-72 hours of onset, while 5 patients – later than 72 hours. We have diagnosed necrotizing process located in the head and the neck of the pancreas and peripancreatic space in all these patients (“Model III”). Results . Positive results related to transpapillary stent placement were noted in 18 patients (72% – main group). Sixteen patients from this group were admitted into hospital in first 24–72 hours, two patients – later than 72 hours from the disease onset. Transpapillary stent placement failed in 7 (28%) patients (control group). Complications in the main group occurred in 2 patients (11,1%): in one case – the dislocation of stent into duodenum and one patient with bleeding after papillosphincterotomy, infected necrotized pancreatitis developed in 4 patients. Mortality observed in 1 case (5.5%). Complications among control group occurred in 2 patients (28.6) – arrosive bleeding, infected necrotized pancreatitis developed in 3 patients. Mortality observed in 1 case (14.3%). Conclusions . Endoscopic transpapillary stent placement is an effective minimally invasive approach in management of patients with necrotizing pancreatitis.

EUS-guided gastroenterostomy versus duodenal stent placement and surgical gastrojejunostomy for the palliation of malignant gastric outlet obstruction: a systematic review and meta-analysis.

Malignant gastric outlet obstruction (GOO) is associated with significant morbidity and decreased quality of life, thereby necessitating effective and safe palliative treatment. As such, we sought to compare endoscopic ultrasound-guided gastroenterostomy (EUS-GE) versus duodenal stent (DS) placement and surgical gastrojejunostomy (SGJ) for palliation of malignant GOO. Searches of electronic databases were performed to identify studies comparing EUS-GE versus DS and/or SGJ for palliative treatment of GOO. Outcomes included technical and clinical success, severe adverse events (SAEs), rate of stent obstruction (including tumor ingrowth), length of hospital stay (LOS), reintervention, and 30-day all-cause mortality. Differences in dichotomous and continuous outcomes were reported as risk difference and mean difference, respectively. Seven studies (n = 513 patients) were included. When compared to DS placement, EUS-GE was associated with a higher clinical success, fewer SAEs, decreased stent obstruction, lower rate of tumor ingrowth, and decreased need for reintervention. Compared to SGJ, EUS-GE was associated with a lower technical success; however, LOS was significantly decreased. All other outcomes including clinical success, SAEs, reintervention rate, and 30-day mortality were not significantly different between an EUS-guided versus surgical approach. EUS-GE was associated with significantly improved outcomes compared to DS placement for palliative treatment of malignant GOO. Despite SGJ possessing a higher technical success compared to EUS-GE, LOS was significantly longer with no difference in clinical success or rate of adverse events.

Pancreaticopleural fistula in a child with chronic pancreatitis harboring compound SPINK1 variants

BackgroundPancreaticopleural fistula (PPF) is a rare complication of chronic pancreatitis (CP) that requires a high index of clinical suspicion in the patient who presents with a pleural effusion. Visualizing the fistula tract from the pancreatic duct to the pleural space by radiological imaging provides confirmation of this complication.Case presentationA 9-year-old boy who presented with massive right pleural effusion secondary to PPF, a complication of CP from a genetic mutation involving two mutations of SPINK1. We successfully managed the case with by endoscopic pancreatic duct stent placement after failure of conservative treatment approaches.ConclusionsPPF is a rare but serious complication of CP in all ages. The diagnosis of PPF in children requires a high index of clinical suspicion and should be considered in the differential diagnosis of massive pleural effusion where pancreatic pathology is present. A high level of pleural fluid amylase and the results from radiological imaging when the patients have symptoms play essential roles in the diagnosis of PPF. Currently, Magnetic resonance cholangiopancreatigraphy (MRCP) is the imaging modality of choice. Endoscopic therapy and surgery are treatment options for patients who do not respond to conservative therapy.

Association of long-term endoscopic biliary stent placement with choledocholithiasis: a literature review.

Endoscopic stone removal is currently the first-line procedure for the treatment of common bile duct stones. Advances in equipment and treatment techniques have expanded the scope of application of endoscopic treatment to include stones that have previously been difficult to remove endoscopically, such as stacked stones and large stones. For the treatment of common bile duct stones in elderly patients in particular, long-term placement of a biliary stent is increasingly being selected. Although periodic stent replacement is required, some reports have stated that biliary stenting is useful in terms of treatment-associated invasiveness and the incidence of accidental complications. To date, various opinions have been presented on whether the treatment of bile duct stones should aim for complete removal of stones or adopt the biliary stenting approach. Findings in previous reports suggest that both the approach for complete stone removal and the long-term stenting approach are associated with advantages and disadvantages. In this study, we reviewed previous reports on the significance of placing a stent and implementing careful monitoring rather than stone removal in patients with bile duct stones.

The Role of Endoscopic Retrograde Cholangiopancreatography in the Management of Biliary Complication Post-Laparoscopic Cholecystectomy

BACKGROUND: Laparoscopic cholecystectomy considers a golden surgery for gallbladder removal nowadays, and it carries some complications like biliary injuries, which can manage successfully by endoscopic retrograde cholangiopancreatography. AIM: To estimate the role of endoscopic management of bile duct injury (BDI) following laparoscopic cholecystectomy. PATIENT AND METHODS: A prospective study conducted at Al-Sader Medical City, Najaf City, Iraq, during the period between September 2018 and December 2020, included 44 patients complicated by the biliary injury resulting in a persistent biliary leak and/or jaundice after laparoscopic cholecystectomy and evaluated by endoscopic retrograde cholangiopancreatography (ERCP). RESULTS: Findings revealed that 25% of cases had complete BDI, only one managed by plastic stent placement, the other 10 referred for open surgical constructions, 61% had partial injury associated with the biliary leak, all managed by sphincterotomy and plastic stent placement through ERCP, almost 7% had a partial clipping of bile duct all managed with sphincterotomy, balloon dilatation/stone extraction, and plastic stent placement, 5% had slipped clips of cystic duct stump, are managed with sphincterotomy and plastic stent placement. Moreover, only one patient, 2%, had distal common bile duct stone with bile leak, managed by sphincterotomy and stone extraction. CONCLUSIONS: Laparoscopic cholecystectomy, a gold standard therapeutic option for symptomatic cholecystolithiasis, is associated with an increased risk of biliary injury due to many factors. ERCP is a safe means of diagnosing the cause of bile leakage after laparoscopic cholecystectomy. It also offers definitive treatment in most cases by endoscopic sphincterotomy and plastic stent placement.

Effectiveness and early postoperative outcomes of palliative endoluminal stenting versus Hartmann's procedure in acute malignant bowel obstruction in high-risk patients.

PurposeThe emergency intervention for acute malignant left-sided colonic obstruction remains controversial. Conflicting reports exist regarding the efficacy and safety of endoscopic placement of self-expandable metallic stents (SEMS) vs. primary surgery. Most reports focus on SEMS insertion as a bridge to surgery.MethodsAn observational nonrandomized study at a single center in Cairo, Egypt included 65 high-risk patients (American Society of Anesthesiologists physical status classification ≥ III, age > 60 years) with acute malignant metastatic (stage IV) colonic obstruction. Twenty-nine patients underwent primary surgery (Hartmann’s procedure, HP), and 35 patients underwent SEMS insertion.ResultsAll cases that underwent SEMS insertion were technically successful. The 2 procedures were comparable in clinical success rates but a statistically significant difference existed between them regarding the duration of postoperative hospital stay in the HP and SEMS group (7.7 ± 3.1 days vs. 3.5 ± 0.6 days, retrospectively; P < 0.001), the interval before regaining oral feeding (41.8 ± 26.8 hours vs. 27.6 ± 18.5 hours, retrospectively; P = 0.015), and the duration of intensive care unit (ICU) admission (5.0 ± 1.7 days vs. 1.5 ± 0.7 days, retrospectively; P = 0.035). Six patients (20.7%) in the HP group and 2 patients (5.7%) in the SEMS group required postoperative ICU admission.ConclusionSEMS placement provides comparable efficacy and safety to HP in managing acute malignant obstruction of the rectosigmoid region in high-risk individuals, with faster recovery and less hospital and ICU admission time.

Effectiveness and Early Postoperative Outcomes of Palliative Endoluminal Stenting Versus Hartmann’s Procedure in Acute Malignant Bowel Obstruction in High-risk Patients

The emergency intervention for acute malignant left-sided colonic obstruction remains controversial. Conflicting reports exist regarding the efficacy and safety of endoscopic placement of self-expandable metallic stents (SEMS) vs. primary surgery. Most reports focus on SEMS insertion as a bridge to surgery. An observational nonrandomized study at a single center in Cairo, Egypt included 65 high-risk patients (American Society of Anesthesiologists physical status classification ≥ III, age > 60 years) with acute malignant metastatic (stage IV) colonic obstruction. Twenty-nine patients underwent primary surgery (Hartmann's procedure, HP), and 35 patients underwent SEMS insertion. All cases that underwent SEMS insertion were technically successful. The 2 procedures were comparable in clinical success rates but a statistically significant difference existed between them regarding the duration of postoperative hospital stay in the HP and SEMS group (7.7 ± 3.1 days vs. 3.5 ± 0.6 days, retrospectively; P < 0.001), the interval before regaining oral feeding (41.8 ± 26.8 hours vs. 27.6 ± 18.5 hours, retrospectively; P = 0.015), and the duration of intensive care unit (ICU) admission (5.0 ± 1.7 days vs. 1.5 ± 0.7 days, retrospectively; P = 0.035). Six patients (20.7%) in the HP group and 2 patients (5.7%) in the SEMS group required postoperative ICU admission. SEMS placement provides comparable efficacy and safety to HP in managing acute malignant obstruction of the rectosigmoid region in high-risk individuals, with faster recovery and less hospital and ICU admission time.

Third time recurrent Boerhaave\u2019s syndrome: a case report

BackgroundEffort rupture of the esophagus or Boerhaave’s syndrome is a rare entity, and prognosis is largely dependent on early diagnosis and treatment. Recurrent effort ruptures are very rare, only reported in a few case reports in English literature. We present a case with a third time effort rupture, and to the best of our knowledge there are no such previous publications. Furthermore, the presented case is also distinct because each episode was treated by different methods, reflecting the pathophysiology of recurrent disease as well as the last decade’s advancements in the management of esophageal perforations in our clinic and globally.Case presentationThe patient is a 60-year-old White male, suffering from alcohol abuse, mild reflux esophagitis, and a history of effort esophageal ruptures on two previous occasions. He was now admitted to our ward once again because of a third bout of Boerhaave’s syndrome. The first time, 10 years ago, he was managed by thoracotomy and laparotomy with primary repair, and the second time, 5 years ago, by transhiatal mediastinal drainage through a laparotomy and endoscopic stent placement. Now he was successfully managed by endovascular vacuum-assisted closure therapy alone.ConclusionsRecurrent cases of Boerhaave’s syndrome are very rare, and treatment must be tailored individually. The basic rationale is, however, no different from primary disease: (1) early diagnosis, (2) adequate drainage of extraesophageal contamination, and (3) restoration of esophageal integrity. Recurrent disease is usually contained and exceptionally suitable for primary endoscopic treatment. To cover the full panorama and difficult nature of complex esophageal disease, endoscopic modalities such as stent placement and endovascular vacuum-assisted closure, as well as the capacity for prompt extensive surgical interventions such as esophagectomy, should be readily accessible within every modern esophageal center.

Management of a Gastrobronchial Fistula Presenting 5 Years After a One-Loop Gastric Bypass

ABSTRACTAnastomotic leaks and gastric fistulas are recognized complications after sleeve gastrectomy and Roux-en-Y gastric bypass. They are, however, almost unheard of following a one-anastomosis gastric bypass. A gastrobronchial fistula, an exceedingly rare complication after bariatric surgery, has to date never been described following a one-anastomosis gastric bypass. Furthermore, there is no consensus regarding the management of this challenging complication. In our case, we present a patient who was discovered to have a gastrobronchial fistula 5 years after a one anastomosis gastric bypass. After 2 failed attempts at endoscopic stent placement, the patient was successfully managed with a laparoscopic Roux-en-Y gastrojejunostomy over the fistula.

Treatment of Hepatic Hydatid Disease: Role of Surgery, ERCP, and Percutaneous Drainage: A Retrospective Study.

Failure to follow the World Health Organization's Informal Working Group on Echinococcosis guidance or having limited experience in the management of cystic echinococcosis (CE) in endemic or nonendemic areas of the world may lead to risky unnecessary procedures. Medical records of all patients undergoing surgery for hepatic hydatid disease at the gastroenterologic surgery and general surgery departments of our hospital between December 2014 and October 2019 were collected and reviewed retrospectively. Demographic characteristics, the size and number of the cysts preoperative liver function tests, surgical treatment, endoscopic retrograde cholangiopancreatography (ERCP), percutaneous drainage (PD), morbidity, and treatment outcomes were reviewed. Of 122 patients included in the study, 77 (63, 1%) were female and 45 (36, 9%) were male individuals and their mean age was 44.95 years. CE1 was identified in 13 patients (10.6%) CE2 in 66 patients (54.1%), CE3a in 7 patients (5.8%), CE3b in 28 patients (22.9%), and CE4 in 8 patients (6.6%). Twenty patients (16.4%) with a cystobiliary fistula in the liver, obstructive jaundice, and postoperative bile leak underwent ERCP. PD was performed in patients with fluid in the hepatic hydatid cyst pouch, increased pouch size because of bile collection, and clinical symptoms postoperatively. Patients presenting with persistent bile leak despite PD underwent ERCP and were treated with endoscopic sphincterotomy and stent placement. Patients with PD were followed by keeping the percutaneous drain open and closed for a while to create pressure difference in the cyst pouch after ERCP. The percutaneous drain was removed in the next 14 to 21 days after checking the pouch size, whereas the common bile duct stents were removed 2 months later after performing a follow-up cholangiography. ERCP should be the primary method for the diagnosis and treatment for hepatic hydatid cysts ruptured into the ducts. İn some cases, high-flow hydatid cysts with rupture into the bile ducts or persistent biliary fistulas can be treated with ERCP and endoscopic sphincterotomy, biliary stent, PD, and nasobiliary drainage without the need for surgical intervention.

Predictors of stent dysfunction in patients with bilateral metal stents for malignant hilar obstruction.

For unresectable hilar obstruction, restoring and maintaining biliary ductal patency are crucial for improved survival and quality of life. The endoscopic placement of stents is now a mainstay of its treatment, and bilateral stenting is effective for biliary decompression. This study aimed to determine the clinical outcomes of bilateral metal stent placement using large cell-type stents and the clinical predictors of stent dysfunction in patients with malignant hilar obstruction. We performed a retrospective analysis of patients who underwent bilateral metal stent placement using two large cell-type stents at two academic teaching hospitals between September 2017 and February 2019. The primary outcome was stent dysfunction. Secondary outcomes included predictors related to stent dysfunction and overall survival. The study included 87 patients who underwent bilateral metal stent placement for malignant hilar obstruction. Technical success and clinical success were achieved in 80 patients (92.0%) and 83 patients (95.4%), respectively. During the follow-up period (median: 201, range: 18-671 days), stent dysfunction occurred in 42 patients (48.3%), and the median stent patency was 199 days (95% confidence interval [CI]: 181-262). In univariate analysis, age, cholangitis before stent insertion, and subsequent chemotherapy were found to be associated with the cumulative risk of stent dysfunction. In multivariate analysis, cholangitis before stent insertion (hazards ratio [HR]: 2.26, 95% CI: 1.216-4.209, P = 0.010) and subsequent chemotherapy (HR: 0.250, 95% CI: 0.130-0.482, P<0.001) remained as statically significant factors associated with the cumulative risk of stent dysfunction. The median overall survival was 288 days (95% CI: 230-327). The bilateral placement of large cell-type stents for malignant hilar obstruction was effective with high technical and clinical success rates and acceptable patency. Cholangitis before stent insertion was associated with shorter patency, and subsequent chemotherapy was associated with longer stent patency.

Combined management of esophagopericardial fistula sustained after catheter ablation for atrial fibrillation

Radiofrequency ablation (RFA) is an effective treatment modality for atrial fibrillation (AF); however, serious complications can occur. We present the case of a highly morbid consequence, the esophagopericardial fistula (EPF). A hemodynamically unstable patient with a history of AF and recent RFA presented with chest pain and was found to have pneumopericardium and pericardial effusion. The patient went to the operating room emergently for combined management with surgical pericardial window and endoscopic stent placement. EPF must be on the differential diagnosis while evaluating patients who develop constitutional symptoms or sudden onset chest pain days or weeks after catheter ablation for AF. Early detection followed by aggressive management with a combined surgical and endoscopic approach may be considered for successful treatment of this type of postablation esophageal perforation if an atrioesophageal fistula is effectively ruled out.

Indocyanine green perfusion assessment of the gastric conduit in minimally invasive Ivor Lewis esophagectomy.

Anastomotic leak is a serious complication following esophagectomy. The aim of the study was to report our experience with indocyanine green fluorescence angiography (ICG-FA)-PINPOINT® assisted minimally invasive Ivor Lewis esophagectomy (MILE) and assess factors associated with anastomotic leak. We reviewed consecutive patients undergoing MILE from 2013 to 2018. Intraoperative real-time assessment of gastric conduit was performed using ICG-FA with PINPOINT®. Perfusion was categorized as good perfusion (brisk ICG visualization to conduit tip) or non-perfusion (any demarcation along the conduit). 100 patients (81 males, median age 68 [60-72]) underwent MILE for malignancy in 96 patients and benign disease in 4 patients. There were six anastomotic leaks all managed with endoscopic stent placement. There was no intraoperative mortality and no 30-day mortality in leak patients. Patients with a leak were more likely to be overweight with BMI > 25 (100% versus 53%, p = 0.03), have pre-existing diabetes (50% versus 13%, p = 0.04), and have higher intraoperative estimated blood loss (260mL [95-463] versus 75mL [48-150], p = 0.03). Anastomotic leaks occurred more frequently in the non-perfusion (67%) versus the good perfusion category (33%, p = 0.03). By multivariable analysis, diabetes (odds ratio [OR] 6.42; p = 0.04) and non-perfusion (OR 6.60; p = 0.04) were independently associated with leak. Intraoperative use of ICG-FA may be a useful adjunct to assess perfusion of the gastric conduit with non-perfusion being independently associated with a leak. While perfusion plays an important role in anastomotic integrity, development of a leak is multifactorial, and ICG-FA should be used in conjunction with the optimization of patient and procedural components to minimize leak rates. Prospective, randomized studies are required to validate the interpretation, efficacy, and application of this novel technology in minimally invasive esophagectomies.

Robotic-assisted ureteral reimplantation and psoas hitch after ureteral injury during cesarean section.

Ureteral injury during gynecological surgery can be managed in a variety of ways, from endoscopic stent placement to ureteroneocystotomy with accompanying psoas hitch and/or Boari flap. The majority of these occur during hysterectomy; therefore, gynecologic surgeons may not be as familiar with repair in women with intact uteri. Herein we present our technique for delayed robotic-assisted ureteral reimplant and psoas hitch in a woman with a ureteral injury sustained during cesarean section, which initially presented as a uretero-cervical fistula. In this video, we describe the evaluation and surgical management of a patient with delayed recognition of a left distal ureteral injury sustained during cesarean section. We present necessary modifications to robotic-assisted laparoscopic ureteroneocystostomy and psoas hitch to accommodate an intact uterus including the need for uterine manipulation, division of the round ligament, bladder mobilization from the lower uterine segment and development of the retropubic space, reimplantation steps, and psoas hitch. Simple modifications to a traditional technique of robotic-assisted ureteroneocystotomy effectively compensate for the presence of a uterus. Obstetricians should maintain a high index of suspicion for ureteral injury in women with new-onset severe urinary leakage post-cesarean section.

A Case of Gastric Neuroendocrine Carcinoma for which Bridge to Surgery by Endoscopic Stent Placement was Effective for Gastroduodenal Stenosis during Preoperative Chemotherapy

A Case of Gastric Neuroendocrine Carcinoma for which Bridge to Surgery by Endoscopic Stent Placement was Effective for Gastroduodenal Stenosis during Preoperative Chemotherapy

Percutaneous Enteral Stent Placement Using a Transhepatic Access for Palliation of Malignant Bowel Obstruction after Surgery.

ObjectiveTo assess the safety and clinical efficacy of percutaneous transhepatic enteral stent placement for recurrent malignant obstruction in patients with surgically altered bowel anatomy.Materials and MethodsBetween July 2009 and May 2019, 36 patients (27 men and 9 women; mean age, 62.7 ± 12.0 years) underwent percutaneous transhepatic stent placement for recurrent malignant bowel obstruction after surgery. In all patients, conventional endoscopic peroral stent placement failed due to altered bowel anatomy. The stent was placed with a transhepatic approach for an afferent loop obstruction (n = 27) with a combined transhepatic and peroral approach for simultaneous stent placement in afferent and efferent loop obstruction (n = 9). Technical and clinical success, complications, stent patency, and patient survival were retrospectively evaluated.ResultsThe stent placement was technically successful in all patients. Clinical success was achieved in 30 patients (83.3%). Three patients required re-intervention (balloon dilatation [n = 1] and additional stent placement [n = 2] for insufficient stent expansion). Major complications included transhepatic access-related perihepatic biloma (n = 2), hepatic artery bleeding (n = 2), bowel perforation (n = 1), and sepsis (n = 1). The 3- and 12-months stent patency and patient survival rates were 91.2%, 66.5% and 78.9%, 47.9%, respectively.ConclusionPercutaneous enteral stent placement using transhepatic access for recurrent malignant obstruction in patients with surgically altered bowel anatomy is safe and clinically efficacious. Transhepatic access is a good alternative route for afferent loop obstruction and can be combined with a peroral approach for simultaneous afferent and efferent loop obstruction.

Rendezvous for afferent limb syndrome

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgical alterations in the normal biliary anatomy is technically challenging. We describe the case of a 73-year-old patient with an afferent limb syndrome secondary to a Whipple procedure for pancreatic cancer, in which a percutaneous rendezvous technique assisted in the endoscopic metallic stent placement with favorable outcome.

Endoscopic radiofrequency ablation plus plastic stent placement versus stent placement alone for unresectable extrahepatic biliary cancer: a multicenter randomized controlled trial

We sought to compare the efficacy and safety between endoscopic radiofrequency ablation (RFA) and stent placement alone in patients with unresectable extrahepatic biliary cancer (EBC). In this randomized controlled trial, patients with locally advanced or metastatic cholangiocarcinoma (CCA) or ampullary cancer who were unsuitable for surgery were recruited from 3 tertiary centers. Eligible patients were randomly assigned to RFA plus plastic stent placement (RFA group) or plastic stent placement alone (stent placement alone group) in a 1:1 ratio. Both groups underwent 2 scheduled interventions with an interval of approximately 3 months. The primary outcome was overall survival (OS). Altogether, 174 participants completed the 2 index endoscopic interventions. No significant differences in baseline characteristics were noted between the 2 groups. The median OS was significantly higher in the RFA group (14.3 vs 9.2 months; hazard ratio, .488; 95% confidence interval, .351-.678; P< .001). A survival benefit was also shown in patients with CCA (13.3 vs 9.2 months; hazard ratio, .546; 95% confidence interval, .386-.771; P< .001). However, no significant between-group differences were found in jaundice control or stent patency duration. The postprocedural Karnofsky performance scores were significantly higher in the RFA group until 9 months (all P< .001). Adverse events were comparable between the 2 groups (27.6% vs 19.5%, P= .211), except for acute cholecystitis, which was more frequently observed in the RFA group (9 vs 0, P= .003). Compared with stent placement alone, additional RFA may improve OS and quality of life of patients with inoperable primary EBC who do not undergo systemic treatments. (Clinical trial registration number: NCT01844245.).

Hydrocephalus and Dandy- Walker Malformation: a review

Introduction: Dandy Walker malformation (DWM) is characterized by agenesis or hypoplasia of the cerebellar vermis, cystic dilatation of the fourth ventricle leading to an increase of the posterior fossa and superior dislocation of the lateral sinus, tentorium and torcula. Although it is the commonest posterior fossa malformation, its pathogenesis is still not fully understood, making the differential diagnosis with other posterior fossa malformations difficult and as a result the choice of therapeutic strategy. Material and methods: An extensive review of the literature relating to Dandy Walker malformation was performed. Historical, genetic, embryologic, epidemiologic, clinical and radiological presentation, treatment and prognosis were revised. Conclusion: The correct diagnosis of Dandy Walker malformation can be made through careful interpretation of magnetic resonance imaging (MRI) and cerebrospinal fluid (CSF) flow studies. The choice of hydrocephalus treatment depends on whether there is aqueduct stenosis. And, although ventriculoperitoneal (VP) shunts have been the treatment of choice for many years, neuroendoscopic techniques such as endoscopic thirdventriculostomy and stent placement are being frequently performed lately.

S1525 Bilothorax: A Rare Complication of Transarterial Chemoembolization of Hepatocellular Carcinoma

INTRODUCTION: A Bronchobiliary fistula (BBF) is an abnormal communication between the bronchial system and the biliary tree. When this occurs, the direct flow of bile from the biliary system to the pleural space can lead to increased lung parenchymal irritation and subsequent inflammatory response with coughing up of bile, also known as bilioptysis. CASE DESCRIPTION/METHODS: A 71-year-old man presented with a five-day history of coughing up greenish watery fluid. He was diagnosed with Hepatocellular Carcinoma years prior and underwent transarterial chemoembolization a month prior. Work up revealed polymicrobial bacteremia and computed tomography (CT) of the chest revealed right lower lobe patchy consolidations. He had minimal improvement with aggressive antibiotics thus repeat CT was done which revealed a right lower lobe abscess immediately adjacent to the hepatic tumor along the liver (Figure 1). Subsequent hepatobiliary iminodiacetic acid scan then confirmed a communication between the biliary tract and lungs as evidenced by leakage of the radiotracer in the bronchi and trachea (Figure 2). Symptoms resolved after targeted antibiotic therapy, fistula resection, adhesiolysis, and intraabdominal abscess drainage. Repeat Imaging showed resolution of bilothorax (Figure 3). DISCUSSION: Bronchobiliary fistula is the most reported cause of Bilothorax. The mechanism of BBF remains unclear however, biliary obstruction and adhesions may be contributing factors. In our case, the common bile duct and pancreatic duct were likely dilated due to a mechanical effect from a mass in the head of the pancreas or ductal strictures from radioablative therapy. Local inflammation causes adhesions from multiple TACE procedures which promotes recurrent sub-diaphragmatic collections. The increased intraluminal pressure in the biliary system with an adjacent hepatic abscess may have caused diaphragmatic invasion with rupture into the pleural space and subsequent erosion into the bronchial tree causing bilothorax and eventual bilioptysis. Resection of the tumor and fistula tract is recommended but it is associated with a high mortality rate. Decompression of the biliary system can be achieved by endoscopic placement of biliary stents, percutaneous transhepatic biliary drainage or percutaneous drainage of hepatic collections. In cases of recurrent BBF despite non-surgical interventions, percutaneous bronchial embolization shows promise with closure of the distal bronchi near abscess.Figure 1.: Computed tomography of the chest: Right lower lobe pneumonia with air fluid levels indicating an abscess (arrow) immediately adjacent to a hepatic tumor with abscess (arrowhead) along the dome of the liver.Figure 2.: Hepatobiliary iminodiacetic acid scan showing radiotracer uptake in the bronchi and trachea. This is consistent with a fistula between the hepatic and pulmonary abscess.Figure 3.: Computed tomography of the chest demonstrating radiologic resolution of findings after surgical intervention.