Expandable Metal Stents Research Articles

S1382 The Great Imitator: A Case of Early Onset Pancreatic Cancer

INTRODUCTION: Pancreatic cancer (PC) is one of the deadliest malignancies, and represents the fourth leading cause of cancer death in the United States. According to the Surveillance, Epidemiology, and End Results (SEER) registry, fewer than 2 percent of patients with PC are under the age of 45. Those who are diagnosed with PC at a younger age consistently show better outcomes, including overall, progression-free and disease-free survivals. CASE DESCRIPTION/METHODS: We present a case of a 35-year-old woman with past medical history of cholelithiasis status post endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and extraction of choledocholiths followed by cholecystectomy at the age of 20 and morbid obesity status post laparoscopic gastric sleeve at the age of 30 who was referred for ERCP with extraction of choledocholiths. She underwent a magnetic resonance imaging (MRI) which revealed a 3.1 × 2.8 cm mildly heterogeneously enhancing pancreas head mass (Figure 1A) associated with marked upstream dilation of the biliary tree (Figure 1B). Endoscopic ultrasonography (EUS) revealed a 23.7 × 22.1 mm hypoechoic heterogeneous pancreas head mass with ill-defined borders. Fine needle biopsy (FNB) was performed (Figure 2A) with pathology revealing adenocarcinoma (Figure 2B). Due to external compression of pancreas mass on duodenum, major ampulla was not visualized, and ERCP was performed by rendezvous technique in conjunction with interventional radiology (Figure 3A). A transpapillary fully covered self-expanding metal stent (FC-SEMS) was successfully deployed resulting in biliary decompression (Figure 3B). As there was no imaging evidence of metastatic disease, patient was referred for resection with curative intent after neoadjuvant chemotherapy administration. DISCUSSION: PC prevalence in patients under the age of 50 remains rare. Certain risk factors for early onset are similar to those for late onset PC. These include alcohol use, tobacco use, chronic pancreatitis, diabetes mellitus, obesity and previous cholecystectomy or gastrectomy. In early onset PC, special attention should be paid to molecular genetics. The typical oncogenes, such as KRAS and c-Myc, and tumor suppressor genes, such as TP53, CDKN2a and SMAD4, still play a role, however, special attention should be paid to BRCA 1 and BRCA 2 germline mutations, as these patients show a particularly early disease onset. Surgical resection is the only curative therapeutic approach, and early detection is essential to ensure resectability.Figure 1.: (A) MRI axial image displaying pancreatic head mass; (B) MRCP coronal image displaying biliary ductal dilation upstream from pancreatic mass.Figure 2.: (A) EUS image with FNB of pancreatic head mass; (B) pathology slide displaying high magnification image of pancreatic adenocarcinoma.Figure 3.: (A) Biliary access achieved by rendezvous technique with interventional radiology; (B) Transpapillary fully covered self expanding metal stent successfully deployed.

Aortic injuries following stents in bariatric surgery: our experience.

Due to the large number of laparoscopic sleeve gastrectomy (LSG) performed over the last decade, the management of the leak following LSG has been increasingly reported. The role of covered Self Expandable Metal Stents (cSEMS) for the treatment of the leak is still controversial because of the poor tolerance and high risk of complications. The aim of the present study was to analyze the foregut wall perforation and aorta injuries, a very rare but potentially fatal complication, related to the treatment of the leak following LSG using cSEMS. Private hospital, France. An audit was conducted in 2 French tertiary bariatric endoscopic centers focusing on aortic injuries after cSEMS use for leak. We examined and classified the initial procedure, leak characteristics, primary endoscopic treatment, and outcome of endoscopic complication for each eligible case. A total of 5 patients were identified with foregut wall perforation and aorta injuries. All stents were deployed for staple line leak following LSG. The recorded mortality in case of esophageal-aortic injuries related to cSEMS use was 80%. cSEMS are potentially effective tools for the management of foregut leaks in bariatric surgery. The biggest challenges with this approach are stent migration and poor quality of life. Caution is required due to the risk of fatal complications such as foregut wall perforation and aorticinjury.

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.

Radiotherapy after esophageal cancer stenting (ROCS): A pragmatic randomized controlled trial evaluating the role of palliative radiotherapy in maintaining swallow.

4569 Background: Most patients with oesophageal cancer (OC) present with incurable disease; 80% of new cases, and deaths, occur in low and middle income nations. Median survival for advanced disease is 3-5 months, a majority requiring intervention for dysphagia. Insertion of self expanding metal stents is the commonest way of palliating, but dysphagia may recur within three months owing to tumour progression. Evidence reviews have called for trials of combination treatment for OC dysphagia. The ROCS study (funding - UK NIHR programme) examined effectiveness of palliative radiotherapy, following stent, in maintaining swallow. It also examined impact on quality of life, bleeding events, and survival. Methods: A multicentre RCT with follow up monthly for a year. Patients referred for stent insertion as primary management of dysphagia related to incurable OC were recruited in secondary care, with all planned follow up at home. Patients were randomised 1:1 to stent insertion alone or stent insertion plus palliative radiotherapy at a dose of 20Gy in five fractions or 30Gy in ten fractions. Primary outcome was difference in proportions of participants with recurrent dysphagia at 12 weeks, defined as deterioration of 11 points or more in the dysphagia scale of the EORTC QLQ-OG25 questionnaire. Secondary outcomes included quality of life, bleeding risk, survival. Results: 220 patients were randomised Dec 2013-Aug 2018 at 23 UK sites. Addition of radiotherapy did not reduce the proportion of primary events at 12 weeks: 49% in control arm vs 45% in the intervention, adjusted OR 0.82 (95%CI 0.40-1.68; p = 0.587) and it was less cost effective. Sensitivity analyses did not alter the results. Dysphagia deterioration-free survival was similar in both arms: adjusted HR 0.92 (95%CI 0.68-1.26; p = 0.618). Median survival was 19.7 weeks in control arm and 18.9 weeks in the intervention. Those in the radiotherapy arm had significantly fewer bleeding events (18.6% compared to 10.3%), giving a number needed to treat of 12. Conclusions: Palliative external beam radiotherapy is widely accessible to patients with advanced cancer. ROCS is the largest trial assessing its role in combination with stenting for OC dysphagia, and is the first to prospectively assess impact on bleeding risk. It demonstrates no reduction in risk of dysphagia recurrence at 12 weeks, nor impact on survival. Reductions in bleeding events should be considered in the context of patient described trade offs of fatigue and burdens of attending hospital. Clinical trial information: NCT01915693 .

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.

Airway complications after lung transplantation: benefit of a conservative bronchoscopy strategy.

BackgroundAfter lung transplantation (LT), between 2% and 25% of bronchial anastomoses develop complications requiring therapeutic intervention. The status of healing of both bronchial anastomoses and downhill airways are well described by the French consensual MDS standardized grading system (Macroscopic, Diameter, Suture). We analyzed risks factors for airway complications (AC) after transplantation and the way we managed them. We report here our challenging method of early rigid bronchoscopic intervention with airway stenting on bronchial healing.MethodsAll single center consecutives LTs were retrospectively analyzed between 2010–2016. Patient-level data (demographic, peri-operative data) and anastomosis-level data (surgical parameters, bronchoscopy findings) were monitored. The incidence and contributive factors of ACs are reported. We also reported modalities of the conservative treatment and outcome.ResultsA total of 121 LTs were performed, 39 single-lung and 82 bilateral sequential LT. Main indication for LT were cystic fibrosis (45%) and emphysema (25%) and 58 were male patients (n=70). After a waiting period of healing, 28 patients presented AC on 41 anastomoses (prevalence: 23%). A multivariate analysis found as contributive factors of ACs, post-operative infection by Aspergillus [odds ratio (OR) 2.7, 95% confidence interval (CI): 1.08–6.75; P=0.033] at the patient level, and at the anastomosis level, emphysema (OR 2.4, 95% CI: 1.02–5.6; P=0.045), early dehiscence (OR 11.2, 95% CI: 1.7–76; P=0.01) and cold ischemia time >264 min (OR 2.45, 95% CI: 1.08–5.6; P=0.03). All the 41 ACs were managed conservatively with rigid bronchoscopy (range, 1–10), 41 stents (21 in silicone and 20 fully-covered Silicone Expandable Metallic Stents) without major complication. Two AC were still under regular bronchoscopic care and silicone stenting for long left bronchus reason. No surgical intervention was needed. The 2-years overall survival rate where not different between AC group and controls, respectively 85% and 81%.ConclusionsAirway healing after transplantation remains a scalable process and the French consensual MDS classification helped us for therapeutic decisions. Rigid bronchoscopy and safety use of current stenting devices may have the pivotal role in the conservative management of ACs, avoiding perilous situation of surgery for AC. Despite a high rate of AC, their favorable evolution may be explained by the cautious care of airway healing and maybe by the use of the Celsior antioxidant solution.

Paediatric acute pancreatitis: Clinical profile and natural history of collections

Background & aimsAcute Pancreatitis (AP) tends to have a benign course in children. However there is a paucity of information with respect to severity of AP in children, the categorization of collections viz., walled off necrosis (WON)& pseudocyst and their natural history & outcomes. MethodsA retrospective medical record review of 187 children with pancreatitis diagnosed and managed at our centre was performed. Results101 children (59% boys, Median age 9yrs) had AP of which 37.6%, 60.4% and 2% had mild, moderately severe and severe AP. 61.4%(62) had PFC at diagnosis; 34%(21) acute pancreatic fluid collections (APFC) and 66%(41) acute necrotic collections (ANC). 52.3%(11of21) of APFC evolved into pseudocysts & 68.2%(28of41) of ANC into WON’s. Drainage was required in 31%(12of39) of persisting collections, more frequently in children with traumatic AP. Percutaneous catheter drainage (PCD) was done in 6 children and endoscopic ultrasound (EUS) guided cystogastrostomy with placement of plastic or self expanding metal stents (SEMS) in 6 children. ConclusionsModerately severe AP is common in hospitalized children with AP with PFC developing in 61.4%, majority being APFC. 48% of APFC and 32% of ANC will resolve and the rest evolve into pseudocyst or WON. Spontaneous resolution is more likely in children with non -traumatic AP having pseudocysts rather than WON’s.

Metallic biliary stenting versus surgery for palliation of inoperable distal malignant obstructive jaundice

Background Pancreatic and biliary malignancies are rarely operable. The role of intervention is to palliate jaundice. Biliary drainage can be done by surgical bypass or biliary stenting either percutaneously or by endoscopic retrograde cholangiopancreatography. Plastic and expandable metal stents (EMS) are available.Aim To compare metallic biliary stenting versus surgery for palliation of inoperable malignant obstructive jaundice due to unresectable pancreatobiliary cancer.Patients and methods This retrospective, cohort study included 43 patients, presented by malignant obstructive jaundice due to unresectable pancreatobiliary cancer. They were divided into two groups: group I (20 patients) underwent palliative biliary-enteric surgical bypass; group II (23 patients) underwent endoscopic retrograde cholangiopancreatography and metal stent drainage.Results This study showed that both surgical bypass and EMS insertion have similar short-term satisfactory results in the control of jaundice. Surgical bypass had low incidence rate as regards late complications, although gastric outlet obstruction may occur for patients without gastric bypass. Despite EMS resulted in a shorter hospital stay, the higher late complications rate raised the cost, especially stent occlusion.Conclusion Endoscopic EMS and surgical bypass had similar results according to the efficacy of biliary drainage and mean survival period. EMS had a shorter hospital stay and fewer early complications. But, in the long run, surgical bypass results in less recurrent jaundice than the EMS but higher morbidity and mortality.

898 Antireflux Valve Metal Stent vs. Conventional Self Expandable Metal Stent in Distal Malignant Biliary Obstruction: A Systemic Review and Meta-Analysis

INTRODUCTION: In patients with distal malignant biliary obstruction (MBO), endoscopic biliary drainage by using the conventional self-expandable metal stent (cSEMS) is the gold standard established method for palliative treatment. However, there are limited data on the role of the antireflux valve metal stent (ARVMS). The aim of this study is to compare the efficacy and safety of ARVMS and cSEMS. METHODS: We performed an electronic search including PubMed, MEDLINE, EMBASE and Cochrane Library following the Preferred Reporting Items for Systemic Review and Meta-analysis (PRISMA) from inception until April 2019. We included randomized controlled trials (RCTs) that studied the efficacy and safety of ARVMS vs cSEMS deployment in distal malignant biliary obstruction. The selected studies provided data regarding technical and clinical success rates. Adverse events and stent dysfunction were also analyzed. We assessed the risk of biases using Cochrane Collaboration tool to assess the risk of bias. RESULTS: A total of 3 RCT’s were selected, enrolling 293 patients (147 ARVMS and 146 cSEMS). The rate of technical success between the ARVMS and cSEMS groups was 95.23% and 99.31% [odds ratio (OR) 0.13; 95% Confidence Interval (95% CI) 0.01-1.06, P = 0.06]. The clinical success rate was 91.57% and 89.36% (OR: 1.30; 95% CI: 0.48-3.51, P = 0.61). There was no significant difference in terms of adverse events between ARVMS and cSEMS (OR: 0.61; 95% CI: 0.35-1.05, P = 0.07). Overall, there was no statistical significance in stent dysfunction (OR: 0.77; 95% CI: 0.48-1.24, P = 0.29), however; after performing sub analysis stent migration was significantly higher in ARVMS (OR: 2.76; 95% CI: 1.24-6.17, P = 0.01). Stent occlusion was significantly lower in ARVMS (OR: 0.44; 95% CI: 0.26-0.76, P = 0.003). CONCLUSION: Our study showed that ARVMS and cSEMS technical and clinical success rates were similar. Adverse events were comparable between two arms. ARVMS was associated with lower risk of stent occlusion. Further randomized controlled trials are required with a higher number of patient population to verify the benefit of ARVMS.

2151 Size Matters: A Case of Recurrent Proximal Esophageal Stenosis Treated With a Biliary Self Expanding Metal Stent (SEMS)

INTRODUCTION: Esophageal stenosis after radiotherapy occurs in up to 15% of patients within 3 months of treatment. Endoscopic dilation remains the standard of care for cervical esophageal stenosis with refractory cases requiring stenting. Proximal stenosis pose a challenge as standard esophageal stents can cause cervicalgia and globus sensation due to their size and expansive force making the a biliary SEMS a better solution. CASE DESCRIPTION/METHODS: Patient is a 72 year-old Vietnamese male with pertinent past medical history of stage IV laryngeal cancer status post total laryngectomy, radiotherapy, and tracheostomy presenting with recurrent dysphagia. Patient had previously undergone four endoscopic dilations within the previous month for the same complaint. Upper endoscopy at time of admission revealed a recurrent benign stricture at the level of the upper esophageal sphincter. Given previous failed dilations, severity of stricture, and patient’s refusal for surgical correction or a gastrostomy tube, a biliary SEMS was placed with palliative intent. A fully covered biliary SEMS measuring 10 mm × 60 mm was deployed at the level of the stricture resulting in symptom resolution for 5 months. On recurrence of dysphagia, evaluation revealed distal migration of the SEMS. Retrieval was unsuccessful and the existing SEMS was overlapped with another 10 mm × 60 mm biliary SEMS which resulted in a symptom-free interval of 11 months. Both SEMS were retrieved and exchanged for a fully covered esophageal SEMS (18 mm). Patient had persistent symptoms and endoscopy revealed proximal migration of the esophageal SEMS. The esophageal SEMS was retrieved and a biliary SEMS (10 mm) was again deployed at the level of the stricture which resulted in resolution of symptoms. Patient has since had the stent exchanged every 3-4 months due to stent migration. DISCUSSION: Recurrent proximal esophageal stenosis pose a challenge for endoscopists due to their challenging anatomy. Standard esophageal stents currently available in the market start at a diameter of 12 mm making it less ideal for proximal esophageal strictures that cannot tolerate the expansive force of the larger stents. We have demonstrated the success of using a smaller-diameter biliary stent for the relief of dysphagia along with longer symptom-free intervals when compared to dilation and standard esophageal stents. This case demonstrates the need for further research and development of specialized esophageal stents for the treatment of recurrent proximal esophageal stenosis.

1390 Impacted Fully Covered Self-Expanding Metal Biliary Stent Within an Uncovered Metal Stent by Exuberant Granulation Tissue Growth Successfully Removed After Treatment With Argon Plasma Coagulation (APC)

INTRODUCTION: We describe the case of an impacted, fully covered, self-expanding metal biliary stent within an uncovered metal stent because of exuberant granulation tissue growth at the ampullary orifice. The stent was successfully removed after treatment of granulation tissue with Argon Plasma Coagulation (APC). CASE DESCRIPTION/METHODS: A 95-year-old lady underwent placement of an uncovered self-expanding metal stent for a tight stricture of the distal bile duct by another gastroenterologist several years ago. The stricture was initially felt to be a malignant stricture but subsequently turned out to be a benign stricture. However, the biliary tree was frequently obstructed with excessive tissue ingrowth and recurrent stone formation requiring placement of a fully-covered self expanding metal stent within the uncovered metal stent, exchanged every nine months. During one of the ERCPs for stent exchange, the covered metal stent could not be removed because of exuberant growth of granulation tissue around the ampullary orifice covering the edges of the stent. The stent was left in place, the stones were extracted with a stone-extraction balloon and the granulation tissue was treated with APC. The plan was to bring the patient back for an ERCP and stent exchange after resolution of the granulation tissue. The patient ended up being hospitalized with stent occlusion and cholangitis after three months. At that time an ERCP was performed and the granulation tissue was noted to have completely resolved. The stent was occluded with stones and debris. The stent was removed without difficulty and a new stent was placed. The same exact situation recurred two years later. The granulation tissue was treated again with APC and stent was cleaned out with a stone-extraction balloon. The patient was brought back in three months for an ERCP and easy stent removal. DISCUSSION: Fully covered self-expanding metal stents have been used successfully for a variety of malignant and benign conditions and are generally easily removable. Occasionally exuberant growth of granulation tissue at the biliary orifice can preclude stent removal. Attempts to remove the stent forcibly can result in stent disruption and can lead to serious complications. In these situations the best approach is to treat the granulation tissue with APC and bring the patient back after resolution of the granulation tissue for an easy stent exchange.

2617 Duodenal Leiomyosarcoma: A Rare Cause of Gastric Outlet Obstruction

INTRODUCTION: Intestinal leiomyosarcoma (LMS) is a rare cancer comprising 0.2% of all malignant tumors and involves the ileum in nearly half of cases. The remainder occur in the proximal duodenum and jejunum primarily, or metastatically from non-intestinal sites such as the uterus. We report this case of primary duodenal LMS complicated by gastric outlet obstruction. CASE DESCRIPTION/METHODS: A 57 year old woman presented with a two month history of worsening epigastric and right upper quadrant pain without nausea, vomiting, weight loss, or altered bowel habits. On physical exam she had marked epigastric tenderness. Abdominal contrast CT demonstrated multiple hypodense liver lesions measuring up to 2cm and a mildly dilated and thickened descending segment of the duodenum. Laboratory evaluation including tumor markers was normal. Without a clear primary malignancy source, the patient underwent percutaneous liver biopsy. Histopathology revealed high grade smooth muscle sarcoma, which stained positively for desmin, SMA, CD 57, and CD 34. Chemotherapy with gemcitabine and docetaxel was initiated per oncology. Within weeks, the patient developed worsening abdominal pain, nausea, and vomiting. CT imaging showed a mass projecting over the descending duodenum causing gastric outlet obstruction. After nasogastric decompression, the patient underwent an EGD. A friable, circumferential mass was seen emanating from distal duodenal bulb extending proximally to the second portion. A duodenal self expanding metal stent was inserted from just proximal to the ampulla to the distal antrum, effectively bridging the mass. Biopsy of the mass was consistent with high grade sarcoma, identical to the liver biopsy. Upper GI contrast series confirmed stent patency; patient tolerated an appropriately advanced diet, and was discharged home to continue outpatient chemotherapy. DISCUSSION: Based on our literature review, there have been no documented cases of gastric outlet obstruction secondary to duodenal LMS. Such tumors often present with abdominal pain and bleeding due to their highly vascular nature. In general, small intestinal malignancies are rare and often difficult to diagnose due to non-specific symptomatic progression resulting in delayed evaluation. Disease is often advanced to lymphatic spread or metastasis at diagnosis as was the case in our patient. A broad differential diagnosis should be considered in patients with unclear primary malignancies presenting with obstructive symptoms.

The Future of Cardiovascular Stents: Bioresorbable and Integrated Biosensor Technology.

Cardiovascular disease is the greatest cause of death worldwide. Atherosclerosis is the underlying pathology responsible for two thirds of these deaths. It is the age‐dependent process of “furring of the arteries.” In many scenarios the disease is caused by poor diet, high blood pressure, and genetic risk factors, and is exacerbated by obesity, diabetes, and sedentary lifestyle. Current pharmacological anti‐atherosclerotic modalities still fail to control the disease and improvements in clinical interventions are urgently required. Blocked atherosclerotic arteries are routinely treated in hospitals with an expandable metal stent. However, stented vessels are often silently re‐blocked by developing “in‐stent restenosis,” a wound response, in which the vessel's lumen renarrows by excess proliferation of vascular smooth muscle cells, termed hyperplasia. Herein, the current stent technology and the future of biosensing devices to overcome in‐stent restenosis are reviewed. Second, with advances in nanofabrication, new sensing methods and how researchers are investigating ways to integrate biosensors within stents are highlighted. The future of implantable medical devices in the context of the emerging “Internet of Things” and how this will significantly influence future biosensor technology for future generations are also discussed.

Management of portal cavernoma-associated cholangiopathy: Single-centre experience

Portal cavernoma associated cholangiopathy (PCC) is an uncommon disease in western countries. We describe our experience in seven patients with PCC, in particular the endoscopic management. We describe the mode of presentation, frequent symptoms and the outcome of different treatment modalities of patients with symptomatic PCC. Prospectively maintained database was reviewed at a large tertiary referral unit in London, UK. Data included therapeutic interventions, outcomes and complications. Seven patients with PCC were followed for a median of 87 months [interquartile range (IQR), 62-107.5]. Causes of EHPVO included (hypercoagulable status, n=2, peritoneal tuberculosis n=1, neonatal sepsis, n=1, idiopathic, n=3). Acute cholangitis constituted the most recurring complications in all patients during the disease course. Endoscopic intervention was deemed required in all patients for biliary decompression, with 5 out 7 patients managed with repeat endoscopic sessions, (total=23 ERCPs). Surgical portal decompression (meso-caval shunt) was successfully performed in one patient and another patient underwent liver transplantation for decompensated liver cirrhosis. When endoscopic intervention was indicated, a fully covered self expanding metal stent (FcSEMS) provided a longer "symptoms free" period when compared to plastic stent, 7.5 (IQR, 4.75-18.25) and 4 (IQR, 3.5-7) months respectively, P=0.03. Bile duct bleeding occurred in two patients during ERCP procedure, however none of the patients had spontaneous haemobilia. Both patients were successfully treated by FcSEMS. Acute cholangitis is a common presentation and recurrent complication during the disease course. Spontaneous haemobilia seems to be uncommon, however it is a significant potential hazard during endoscopic intervention. Insertion of FcSEMS may remodel choledochal varices and provide a longer "symptoms free" period compared to plastic stents.

Tu1948 USE OF LUMEN APPOSING METAL STENTS IN TREATMENT OF ENTERIC STRICTURES

Lumen apposing metal stents (LAMS) present a sub-type of fully covered self expanding metal stent that have an FDA indication for symptomatic pancreatic pseudocysts. LAMS have also been used off label for a variety of other purposes including small bowel luminal access and transmural gallbladder drainage. In addition, LAMS have been used to treat enteric strictures. In this study we aimed to collect and analyze cases of enteric strictures treated with LAMS.

Gastrointestinal Endoscopy Editorial Board top 10 topics: advances in GI endoscopy in 2018

The American Society for Gastrointestinal Endoscopy's Gastrointestinal Endoscopy Editorial Board reviewed original endoscopy-related articles published during 2018 in Gastrointestinal Endoscopy and 10 other leading medical and gastroenterology journals. Votes from each individual member were tallied to identify a consensus list of 10 topic areas of major advances in GI endoscopy. Individual board members summarized important findings published in these 10 areas of adenoma detection, bariatric endoscopy, EMR/submucosal dissection/full-thickness resection, artificial intelligence, expandable metal stents for palliation of biliary obstruction, pancreatic therapy with lumen-apposing metal stents, endoscope reprocessing, Barrett's esophagus, interventional EUS, and GI bleeding. This document summarizes these "Top 10" endoscopic advances of2018.

Survival analysis pattern of patients treated with biliary metallic stent versus patients treated with surgical procedures for hepato-biliary malignancies in a rural tertiary care centre in South India

Background: Tumors of the biliary tract show spectrum ranging from benign to malignant lesions. Only 20% of tumors are resectable at the time of presentation. The operative mortality was approximately 5 to 20%. The morbidity rate associated with the surgery is approximately 65%. Options for palliative therapy of biliary tree obstruction include the surgical bypass, percutaneous external drainage/stenting and endoscopic stenting. The aim was to compare the survival pattern of patients treated with biliary Self Expandable Metallic Stents (SEMS) as a palliative procedure to that of patients treated by curative surgery.Methods: This was a retrospective study. 6-months survival pattern were analysed in 20 patients treated by SEMS and compared with that of 10 patients treated with plastic biliary stents followed by curative surgery.Results: Survival pattern analysis was done for all 20 patients with SEMS. 7 patients were in >1-year survival, 5 were in >6months survival, 6 expired within 6months, 2 patients were lost to follow up. Survival pattern was compared with 10 patients who had plastic stents followed by curative surgery. Only 1 patient had survival rate >1year post-surgery, 5 patients expired post-surgery in <6months, 2 patients expired few weeks after plastic stent deployment, 2 patients were lost to follow up.Conclusions: In patients with biliary malignancies with obstruction, biliary SEMS followed up by palliative chemotherapy had better survival rate than patients who had plastic stents followed up with curative surgical procedures.

Colonic Stent Use in Patients With Malignant Flexure Tumors Presenting With Obstruction.

Background and Objective:Colonic stenting in left-sided tumor is being commonly used. However, placing a stent in the flexure tumors is rare because it is technically more difficult. In this study, we aimed to retrospectively screen patients with flexure tumors admitted to our clinic who were treated using a colonic stent and discuss our findings.Methods:Patients admitted to the emergency department for obstructive colonic tumors between 2012 and 2017 were retrospectively evaluated, and 21 patients treated using stents were included in the study. The expandable metal stent (Wallflex®, Boston Scientific, Marlborough, MA, USA) was placed at the obstruction through the lead wire.Results:The mean age of the patients was 62 years, and the ratio of females to males was 3:18. Splenic flexure tumors were detected in 18 patients and hepatic flexure tumors in 3 patients. Seven of the patients were stented for palliative purposes. Fourteen of the cases underwent surgery. Three of them underwent laparoscopic surgery and eleven underwent open surgery.Conclusions:Preoperative stenting in colonic flexura tumors is associated with faster healing, less postoperative complications, lower rates of colostomy, and higher rates of minimally invasive surgery, and can be safely used at experienced centers.

Distal malignant biliary obstruction: a prospective randomised trial comparing plastic and uncovered self-expanding metal stents

Background: The aim of this study was to determine the safety and clinical effectiveness of 10F plastic biliary stents compared to uncovered self expanding metal stents (SEMS) for palliative treatment of patients with inoperable extra-hepatic malignant biliary obstruction in a public hospital in South Africa. Methods: From January 2009 to December 2013, 40 patients who were admitted to a tertiary academic centre because of distal malignant biliary obstruction were enrolled in a prospective randomized study. Patients were randomly assigned to receive an uncovered SEMS or a plastic stent deployed through the biliary stricture during endoscopic retrograde cholangiopancreatography. Results: Median patient survival time in the two groups did not differ significantly (SEMS - 114 days; plastic - 107 days). Stent failure was more common in the plastic stent group (7/19 vs. 1/20). The results became significant after 6 months of follow-up. There was no significant difference between the two groups in the incidence of serious adverse events. Conclusion: SEMSs had a longer duration of patency than plastic stents, which recommends their use in the palliative treatment of patients with biliary obstruction due to distal malignant biliary obstruction.