Expandable Metallic Stent Placement Research Articles

Efficacy of Oesophageal self expandable metal stent placement for palliation of dysphagia in inoperable oesophageal cancer patients: A low-income country perspective

Efficacy of Oesophageal self expandable metal stent placement for palliation of dysphagia in inoperable oesophageal cancer patients: A low-income country perspective

High Output External Biliary Drainage Leading to Acute Kidney Injury in a Patient with Malignant Obstructive Jaundice: A Rare Case Report

Most patients with malignant obstructive jaundice present to the hospital in an advanced unresectable stage. Percutaneous transhepatic biliary drainage (PTBD) and stenting are the established , safe and effective way of palliative treatment aiming prolongation and improving the quality of the life. We report a rare case of high output external biliary drainage leading to AKI and electrolyte imbalance following insertion of PTB drain. Patient was managed with hemodialysis and subsequent self- expandable metallic stent (SEMS) placement. We highlight the importance of awareness of this complication and need of further studies regarding role of biliary interventions, associated complications and management.

Oral intake and survival after the placement of enteric protheses in advanced gastric neoplasms

Background: Malignant gastric outlet obstruction (GOO) is a frequent complication in patients with locally advanced gastric neoplasms. The palliation of the symptomatic obstruction can be performed through surgery or the placement of self expandable metal stents (SEMS). This study acesses the long-term clinical efficacy of SEMS as a paliative treatment in patients with GOO due to gastric cancer.

Patterned Drug-Eluting Coatings for Tracheal Stents Based on PLA, PLGA, and PCL for the Granulation Formation Reduction: In Vivo Studies

Expandable metallic stent placement is often the only way to treat airway obstructions. Such treatment with an uncoated stent causes granulation proliferation and subsequent restenosis, resulting in the procedure’s adverse complications. Systemic administration of steroids drugs in high dosages slows down granulation tissue overgrowth but leads to long-term side effects. Drug-eluting coatings have been used widely in cardiology for many years to suppress local granulation and reduce the organism’s systemic load. Still, so far, there are no available analogs for the trachea. Here, we demonstrate that PLA-, PCL- and PLGA-based films with arrays of microchambers to accommodate therapeutic substances can be used as a drug-eluting coating through securely fixing on the surface of an expandable nitinol stent. PCL and PLA were most resistant to mechanical damage associated with packing in delivery devices and making it possible to keep high-molecular-weight cargo. Low-molecular-weight methylprednisolone sodium succinate is poorly retained in PCL- and PLGA-based microchambers after immersion in deionized water (only 9.5% and 15.7% are left, respectively). In comparison, PLA-based microchambers retain 96.3% after the same procedure. In vivo studies on rabbits have shown that effective granulation tissue suppression is achieved when PLA and PLGA are used for coatings. PLGA-based microchamber coating almost completely degrades in 10 days in the trachea, while PLA-based microchamber films partially preserve their structure. The PCL-based film coating is most stable over time, which probably causes blocking the outflow of fluid from the tracheal mucosa and the aggravation of the inflammatory process against the background of low drug concentration. Combination and variability of polymers in the fabrication of films with microchambers to retain therapeutic compounds are suggested as a novel type of drug-eluting coating.

Perendoscopic Placement of Palliative Stent for Obstructive Jaundice Caused by Head of Pancreas Malignancy in Dr Moewardi General Hospital-Surakarta

Pancreatic cancer is difficult to diagnose in early stage. Malignant bile duct obstruction is a severe complication of pancreatic cancer, which can lead to poor outcomes including cholangitis, delayed treatment, reduced quality of life, and increased mortality. Perendoscopic placement of stents is a method widely used in the management of various malignant and benign pancreatico-biliary abnormalities. A 70-year-old woman came to Dr Moewardi General Hospital in Surakarta with the chief complaint of yellowish skin and eyes since one month before hospital admission. Patient was diagnosed with obstructive jaundice due to suspected of advanced stage pancreatic cancer. Subsequently, patient underwent endoscopic retrograde cholangiopancreatography (ERCP) which revealed an intrahepatic and extrahepatic bile ducts dilatation due to pancreatic tumor which infiltrated common bile duct, thus self expandable metallic stent (SEMS) placement was performed. Furthermore, patients received palliative therapy due to inadequate chemotherapy requirement.

Improved results for left-sided malignant colorectal obstruction with a proper selection for self expandable metal stent placement, surgical resection or diverting stoma

AimsEndoscopic placement of Self Expandable Metal Stents to relieve malignant colorectal obstruction has become a common therapeutic advancement in clinical practice. MethodsIn a 16 year period 145 patients had endoscopic placement of a Self-Expandable Metal Stent for acute/subacute left sided malignant colorectal obstruction in a center where gastroenterologists and surgeons cooperate in a daily basis, discussing indications. ResultsThere was no operative mortality and no major complication in placement of the stent. Technical and clinical success was respectively 94.5% and 91.8%. Consultation among specialists changed the preoperative indication in 60 patients. ConclusionsSelf-Expandable Metal Stents placement represents an important tool to treat patients with obstructing colorectal cancer. Surgical resection, diverting stoma or endoscopic stent placement should be chosen according to the clinical characteristics of each single patient. In this scenario, a close collaboration among specialists in selecting the most appropriate operative procedure is essential and brings to better results.

Fully Covered Self-Expandable Metal Stens eliminate surgical repair requirement in both endoscopic sphincterotomy and precut sphincterotomy-related perforation (with video).

Endoscopic retrograde cholangiopancreatography (ERCP)-related perforations occur in 0.3-0.6% of patients. The treatment of retroperitoneal paravaterian perforations (type II), which develop during endoscopic sphincterotomy or precut sphincterotomy, remains a matter of debate. We aimed to evaluate the efficacy of fully covered self expandable metal stent (Fc-SEMS) placement in the treatment of type II perforations. The study was conducted in a tertiary ERCP reference center of Turkey between December 2013 and June 2016. Patients with type II ERCP-related perforation constituted the study group. Type II perforations were treated by insertion of an Fc-SEMS (10 mm × 60 mm) during the ERCP procedure or intraoperatively by surgery-endoscopy rendezvous technique, if biliary cannulation could not be achieved. A total of 2689 ERCPs were performed. ERCP-related perforation was observed in 12 procedures (0.4%). Eight patients had Stapfer type II perforations, which developed during endoscopic sphincterotomy in seven patients and precut sphincterotomy in one patient. Fc-SEMSs were inserted during the ERCP procedure in seven patients and intraoperatively by surgery-endoscopy rendezvous technique in one patient. None of the patients developed fever, hemodynamic instability, or peritoneal signs. Stents were removed after a median duration of 9 (3-14) days. All of the patients were uneventfully discharged after an average hospital length of stay of median 5 (1-9) days. Fc-SEMSs are highly effective in the nonoperative treatment of type II perforations and their intraoperative insertion in patients with unsuccessful cannulation may facilitate surgery by eliminating the need for duodenum repair surgery.

Treatment of venous stenosis in oncologic patients.

Symptomatic obstruction related to malignant involvement of large veins may occur in central veins both in the thoracic and pelvic regions, and in the abdominal region of the body. Both cases represent a therapeutic challenge, and endovascular revascularization, consisting of angioplasty and stent placement, is safe and effective. Superior vena cava stenting has become widespread in the management of occlusive venous disease. The percutaneous placement of large expandable metal stents allows rapid restoration of normal blood flow in the majority of patients, thus improving symptoms. Published data on the diagnosis and treatment of symptomatic cancer-related iliocaval obstructions are limited and mainly consist of case reports and small case series. The present review reports the current state of endovascular treatment for both superior vena cava occlusion and iliac compression syndrome in cancer patients.

Safety and feasibility of esophageal self- expandable metal stent placement without the aid of fluoroscopy

Self-expandable metal stents (SEMSs) are used for the management of certain esophageal conditions such as strictures, perforations, and fistulae. These can be placed using fluoroscopic control, endoscopic control, or a combination of both. We evaluated our institutional experience of placing a SEMS using only endoscopy without the aid of fluoroscopy to determine safety and feasibility using this technique. A retrospective review was performed to identify all patients who underwent esophageal SEMS from January 2010 to June 2015. Placement of SEMS was accomplished under direct endoscopic visualization without the aid of fluoroscopy. Esophageal lesion was initially identified during endoscopy and a fully covered SEMS was passed over the guide wire and deployed under direct vision. Misplacement of the SEMS during the procedure that required replacement with another new SEMS was considered as a failed procedure. Other periprocedural complications caused by placement of SEMS were noted. A total of 172 patients underwent 280 procedures for SEMS placement. Mean age was 66 years. The most common indication for SEMS placement was stricture in 248 (88%) procedures. Periprocedure SEMS misplacement occurred in 12 (4%) patients. However, only 8 (3%) patients needed to have a new SEMS placed during the same procedure. A total of 64 (23%) patients had migration of SEMS. There were no other periprocedure complications leading to adverse events. Self-expandable metal stent can be placed accurately and safely under direct endoscopic visualization without the aid of fluoroscopy.

一側無気肺にExpandable Metallic Stentを留置した悪性腫瘍5症例の経験

一側無気肺にExpandable Metallic Stentを留置した悪性腫瘍5症例の経験

Treatment of severe tracheobronchomalacia: Ten-year experience

IntroductionPaediatric tracheobronchomalacia is a rare but potentially serious condition. Severe tracheobronchomalacia requires intervention or operation. This is an evaluation of a ten-year experience at an institution. MethodsIn this retrospective study all patients were included that required an intervention for severe tracheobronchomalacia from 2003 to 2012. Symptoms, aetiology, comorbidities, localisation of the malacia, age at diagnosis, therapeutic measures and associated complications were evaluated. ResultsForty-four patients with severe tracheobronchomalacia underwent intervention/operation. The predominant aetiology was vascular compression in 48%. The majority of patients had complex comorbidities, most importantly cardiac pathology in 66%. The median age at diagnosis was 3 months. A total of 17 aortopexies, 21 tracheostomies and 25 stent placements were performed. The mean follow-up was 2.6 years. Severe complications occurred in 12 patients. The most common complications were stent obstruction/fracture and tracheostomy tube obstruction. ConclusionThe management of severe tracheobronchomalacia is complex and the population of patients is very heterogeneous. Therefore the treatment has to be adapted for each patient individually. The decision strategies are discussed in this article. The surgical techniques for placement and safe removal of expandable bare metallic stents employed in our institution are presented. A multidisciplinary team of ENT surgeons, Intensivists, Cardiologists and Cardiac surgeons is of great importance.

Ostomy in Nontraumatic Conditions: Our Experience and Review of the Literature.

A number of nontraumatic acute abdomen can result in peritonitis leading to sepsis. In emergent conditions, various procedures like segmentary colectomy and/or subtotal colectomy with anastomosis, Hartmann's procedure, transverse colectomy, and/or expandable metallic stent (SEMS) placement can be performed, considering the status of the patient and the facilitaties of the institution. In our study, we examined the cases diagnosed as acute abdomen without the history of trauma, which had lead to a procedure requiring colostomy. We retrospectively analysed 105 cases of nontraumatic acute abdomen, resulted in a procedure requiring colostomy. American Society of Anesthesiologists (ASA) scoring and Mannheim Peritonitis Index (MPI) were used in the evaluation of the risk of mortality and morbidity. There were colonic perforations of rectosigmoid tumor in 66 cases (62.8%), sigmoid volvulus in 10 cases (9.5%), colonic anastomotic leakage in 9 cases (8.5%), intestinal adhesions in 8 cases (7.6%), mesenteric ischemia in 5 cases (4.7%), gynecological diseases in 3 cases (2.85%), strangulated hernias in 3 (2.85%), and Ogilvie syndrome in 1 case (0.95%). Rate of morbidity was found to be 25.7%, while mortality occurred in 2.8% of the cases. Cases with mortality and morbidity had ASA scores above two and MPI scores above 23. Anastomotic leakage was the only reason of mortality. In nontraumatic occasions, the management and prognosis of cases with peritonitis, general status of the patients play major roles. The prognosis rates of morbidity and mortality can be highly predicted when ASA and MPI scores are evaluated together.

Migration of retrievable expandable metallic stents inserted for malignant esophageal strictures: incidence, management, and prognostic factors in 332 patients.

The purpose of this study was to evaluate the incidence, prognostic factors, and secondary management of stent migration in patients with malignant esophageal strictures. A retrospective study was performed in a single tertiary referral university hospital to identify the incidence, management, and prognostic factors for stent migration in 332 consecutive patients with placement of a retrievable expandable metallic stent. Stent migration was classified into four patterns as locations of a migrated stent: pattern I, partially migrated in the proximal direction; pattern II, partially migrated in the distal direction; pattern III, completely migrated into the stomach; and pattern IV, completely migrated into the bowel. Stent migration occurred in 42 (12.6%) of 332 patients. Migration was partial (n = 21) or complete (n = 21), and nine (21%), 12 (29%), 11 (26%), and 10 (24%) patients had patterns I, II, III, and IV, respectively. Multivariate analysis identified the following prognostic factors: esophagogastric junction strictures caused by cancer of the gastric cardia (odds ratio 1.330; p = 0.004), patients who underwent anticancer treatment after stent placement (17.514; p < 0.001), and patients with a longer survival time (1.994; p < 0.001). Secondary management was needed for 33 of 42 patients. The strictures in the remaining nine patients improved throughout follow-up. Stent migration occurs most commonly in patients with cancer of the gastric cardia, patients with longer survival time, and those who underwent anticancer treatment after stent placement. Stent migration is successfully managed by further intervention. Accurate knowledge of the pattern of stent migration is important for successful management.

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.

Preliminary Results of Temporary Placement of Retrievable Expandable Metallic Stents during Preoperative Neoadjuvant Chemoradiotherapy in Patients with Resectable Esophageal Cancer

PurposeTo evaluate the clinical efficacy of temporary placement of a retrievable expandable metallic stent (REMS) during preoperative neoadjuvant chemoradiotherapy (CRT) in patients with resectable esophageal cancer. Materials and MethodsREMSs were placed in 25 patients who underwent preoperative neoadjuvant CRT for resectable esophageal cancer. Stent removal was scheduled between 4 and 6 weeks after starting neoadjuvant CRT. Clinical effectiveness was assessed using the following variables: technical and clinical success, dysphagia score before and after stent placement and removal, and complications and their management. ResultsREMS placement was technically successful in all patients, with 24 of 25 patients (96%) showing symptomatic improvement. Stents were removed electively 32 days (range, 27–42 d) after starting neoadjuvant CRT (n = 20; 80%) or after stent migration and exit through the anus with no evidence of symptom recurrence (n = 5; 20%). The dysphagia score (before stent, 3.1 ± 0.5) improved by 3 days after stent placement (1.3 ± 0.4; P < .001) and was maintained up to 1 month after stent removal (1.2 ± 0.7; P < .001). The median survival was 18.6 months. ConclusionsIn patients with resectable esophageal cancer, temporary placement of a REMS during preoperative neoadjuvant CRT showed clinical efficacy in the bridge to surgery. Stent removal between 4 and 6 weeks after starting neoadjuvant CRT seems to be a feasible time frame with symptom improvement.

New ex-vivo porcine model for endoscopic ultrasound-guided training in transmural puncture and drainage of pancreatic cysts and fluid collections (with videos).

Background and Objectives:Endoscopic transmural puncture cysts and drainage pancreatic fluid collections are an important part of endoscopic ultrasound practices, but can be technically difficult to master, particularly with regards to placing stents. We developed an ex-vivo model that is inexpensive and can be used for cyst puncture and fluid collection drainage.Methods:Over the last 5 years, we have perfected the creation of this ex-vivo model. The model is easy and inexpensive to create and multiple aspirations and device placements and removals into a single cavity with decompression. The model allows the use of cautery devices and placement of expandable metal stents. Additionally, the contents in the model can be altered to appear as walled-off necrotic collections endosonographically.Results:The model can be created for <300 US dollars. It has been used at multiple international conferences for teaching purposes and can withstand up to 10 puncture and drainages without having to replace the “cyst.” The cyst can easily be exchanged for other prepared cysts. Preliminary surveys obtained from users show ratings that are realistic.Conclusions:A new ex-vivo model can be easily and economically created, is realistic and can be used multiple times during the single training session.

Multicenter comparative evaluation of endoscopic placement of expandable metal stents for malignant distal common bile duct obstruction by ERCP or EUS-guided approach

A single session of EUS-guided biliary drainage (EUS-BD) may be a viable alternative to ERCP in patients with malignant distal common bile duct (CBD) obstruction. There is no study comparing EUS-BD andERCP for the relief of distal malignant biliary obstruction. To compare the outcomes of self-expandable metal stent (SEMS) placement for malignant distal biliary obstruction by using ERCP and EUS-BD. Multicenter, retrospective analysis. Tertiary referral centers. Patients with malignant distal CBD obstruction requiring SEMS placement. Patients in the EUS-BD group underwent EUS-guided choledochoduodenostomy (EUS-CDS) or EUS-guided antegrade (EUS-AG) procedures after 1 or more failed ERCP attempts. Patients in the ERCP group underwent retrograde SEMS placement. Composite success (the ability to complete the intended therapeutic procedure in a single session and resulting in a greater than 50% decrease in bilirubin over 2 weeks). The study included 208 patients, 104 treated with ERCP and 104 treated with EUS-BD (68 EUS-CDS, 36EUS-AG). SEMS placement was successful in 98 patients in the ERCP group and 97 in the EUS-BD group (94.23% vs 93.26%, P= 1.00). The frequency of adverse events in the ERCP and EUS-BD groups was 8.65% and 8.65%, respectively. Postprocedure pancreatitis rates were higher in the ERCP group (4.8% vs 0, P= .059). The mean procedure times in the ERCP and EUS-BD groups were similar (30.10 and 35.95 minutes, P= .05). Retrospective analysis. In patients with malignant distal CBD obstruction requiring SEMS placement, the short-term outcome of EUS-BD is comparable to that of ERCP.

Mo1363 Multicenter Comparative Evaluation of Endoscopic Placement of Expandable Metal Stents for Malignant Distal CBD Obstruction by ERCP or EUS-Guided Approach

Mo1363 Multicenter Comparative Evaluation of Endoscopic Placement of Expandable Metal Stents for Malignant Distal CBD Obstruction by ERCP or EUS-Guided Approach

Su1625 Y-Shaped Bilateral Self Expandable Metallic Stent Placement (Stent-in-Stent Technique) for Malignant Hilar Biliary Obstruction: Data From a Large Saries of Patients Treated in a Tertiary Referral Center

Su1625 Y-Shaped Bilateral Self Expandable Metallic Stent Placement (Stent-in-Stent Technique) for Malignant Hilar Biliary Obstruction: Data From a Large Saries of Patients Treated in a Tertiary Referral Center

Metallic Stent Placement in Patients with Recurrent Malignant Obstruction in the Surgically Altered Stomach

The purpose of this study was to assess the technical feasibility and clinical effectiveness of expandable metallic stent placement in 196 patients with recurrent malignant obstruction in their surgically altered stomach. The 196 patients were treated using five different types of gastric surgery performed for gastric cancer: total gastrectomy (type 1) in 73 patients; distal gastrectomy with gastroduodenostomy (type 2) in 39 patients; distal gastrectomy with a Roux-en-Y gastrojejunostomy (type 3) in 21 patients; distal gastrectomy with a gastrojejunostomy (type 4) in 49 patients; and palliative gastrojejunostomy for unresectable gastric cancer (type 5) in 14 patients. The technical and clinical success rates, complications, dysphagia score, and influence of chemotherapy were evaluated and the complications compared between the two stent types. The overall survival and stent patency were calculated using the Kaplan-Meier method. Stent placement was technically successful in 192 of 196 patients (97.9%), with 184 of the 192 patients (95.8%) showing symptomatic improvement. The mean dysphagia score improved from 3.24±0.64 to 1.48±0.82 (p<0.001). The complication rate was 25%. The incidence of stent migration was significantly higher in fully covered stents and in patients who underwent chemotherapy (p<0.001 and p=0.005, respectively). Chemotherapy was significantly associated with an increase of survival (p<0.001). The median survival and stent patency were 131 and 90days, respectively. Placement of expandable metallic stents in patients with recurrent cancer after a surgically altered stomach is technically feasible and clinically effective. Chemotherapy was associated with increased stent migration and prolonged survival.