Placement Of Multiple Stents Research Articles

Plastic or Metal Stents for Benign Biliary Obstructions? A Systematic Review of the Literature

Introduction and Aim: Benign biliary strictures occur as a consequence of surgical procedures, chronic pancreatitis or iatrogenic ampullary lesions. Stents are increasingly being used for this indication however it is not clear which type of stent to use for which indication. Methods: A systematic review of the literature on stent placement for benign biliary obstructions was performed after searching PubMed and EMBASE databases. A total of 85 studies on outcome of stent placement in 2265 patients were identified. No randomized controlled trials (RCTs) and two non-randomized comparative studies were found. A total of 83 case-series evaluated 1409 patients with recurrent single plastic stents 329 patients with recurrent multiple plastic stents, 386 patients with uncovered self-expanding metal stents (uSEMS) and 93 with covered SEMS (cSEMS). In most studies plastic stents were electively exchanged every 3 months. Stent exchange was not performed with uSEMS and cSEMS. Data were evaluated and pooled for technical success, clinical success, defined as relief of (obstructive) symptoms and/or a significant decrease in bilirubin, and complications. Results: Indications for stent placement were biliary strictures following surgery (40.0%), chronic pancreatitis (20.2%), liver transplantation (24.3%) or others (15.4%). Median stenting time was longest for uSEMS (20 months (range 0.5-60)) followed by multiple plastic stents (11.8 months (range 4.6-14)), single plastic stent (11.6 months (range 0.3-24)) and cSEMS (4.0 months (range 1-28)). Technical success was 98.5% for uSEMS, 97.6% for multiple plastic stents, 96.5% for cSEMS and 94.1% for single plastic stent placement. Overall clinical success was highest after placement of multiple plastic stents (87.5%) followed by placement of cSEMS (75.0%), uSEMS (62.4%) and single plastic stent (61.2%). Clinical success in chronic pancreatitis was highest after uSEMS placement, whereas after liver transplantation and following surgery, clinical success was highest after placement of multiple plastic stents. Complications occurred least frequently after multiple plastic stent placement (18.5%) followed by single plastic stent (36.5%), cSEMS (39.6%) and uSEMS (49.6%) placement. Conclusion: Based on clinical success and risk of complications, placement of multiple plastic stents seems currently the best choice. The evolving role of cSEMS placement for this indication needs further elucidation in a RCT comparing them with multiple plastic stents.

Viabil Stent in the Management of Pancreatic Pseudocysts

Introduction: Endoscopic drainage is the first line therapy for non-complicated pancreatic pseudocysts. The length and the ideal form of therapy are not established. Current therapies include simple drainage through a wall incision or placement of multiple plastic stents. We describe our experience with a removable self-expanding metal stent (Viabil, Conmed, MA). Patients and Methods: We used the Viabil stent as primary treatment in 8 patients with non-complicated symptomatic pancreatic pseudocyst.

Advanced Translumenal Access Device for Pseudocyst Drainage

Introduction: EUS-guided pseudocyst drainage provides internal drainage without the need for surgical intervention. Current methods require multi-step access through the GI lumen wall into the pseudocyst, creation of a cystgastrotomy tract, and placement of multiple 7-10F plastic stents. Access and dilation steps are often tedious and difficult to perform due to the lack of a suitable stent delivery devices. Herein we describe a fully integrated translumenal access device that creates and dilates an access tract, then facilitates placement of two guidewires.

Short-term Placement of Multiple Self-expandable Metallic Stents for the Treatment of Bilateral Bronchial Dehiscences Complicating Lung Transplantation

Bronchial dehiscence after lung transplantation is a rare complication yet has high morbidity and mortality. The majority of the patients are not surgical candidates. We present the case of a 59-year-old man with bilateral lung transplantation for interstitial pulmonary fibrosis who was readmitted with symptoms of acute rejection and severe hypoxemic respiratory failure on day 14. Bronchoscopy showed bilateral bronchial anastomotic dehiscences. A computerized tomography scan showed evidence of significant peribronchial air collection in the pleural space and the mediastinum. Owing to a high predictive operative mortality, endobronchial management was planned, and 3 uncovered self-expanding metallic stents (Ultraflex, Boston Scientific Corp) were placed (in the left main stem bronchus, the anterior segment of the right upper lobe, and the right intermediate bronchus). At 5 weeks bronchoscopy showed complete healing of the dehiscences with granulation. The stents were then removed by rigid bronchoscopy. Three weeks after the stent removal a bronchoscopic examination showed a normal tracheobronchial tree except for a slightly narrowed right anastomosis. We conclude that short-term placement of uncovered self-expanding metallic stents provides a safe and minimally invasive option in the management of bilateral dehiscences.

Comparison of accessory performance using a novel ERCP mechanical simulator

There is a paucity of in vitro methods for evaluating ERCP accessories. We hypothesize that the time taken to perform a simulated single stent or multiple stents placement is different for stenting systems with or without the capability of intraductal ductal release (IDR) of the guide wire. We conducted an un-blinded in vitro comparison of ERCP accessories using a mechanical simulator during hands-on ERCP practice workshops. A total of 21 U.S. participants and 20 Chinese participants with various level of ERCP experience took part in the different practice workshops. Accessories with and without the capability of intraductal release of guide wire were compared. Total time required for completing a simulated stenting procedure with single or multiple stents and the respective simulated fluoroscopy time were recorded. There was no significant difference in the time taken for placement of a single stent using either stenting systems. Stenting system capable of intraductal release of the guide wire required significantly shorter time to complete placement of three stents. Using time required to complete a specific task, i. e. biliary stenting, the mechanical simulator permits the performance of different accessories by the same group of operators to be evaluated objectively.

Invasive endoscopy or surgery for pancreatic disorders?

Endoscopic double papillotomy occupied the place of surgical transduodenal double sphincteroplasty for disorders of papilla of Vater or chronic pancreatitis several years ago. Endoscopic cystoenterostomy and cystogastrostomy can also replace surgery in the treatment of pseudocysts and walled-of necrosis even in cases of severe acute pancreatitis with/or without sepsis. In chronic pancreatitis endotherapy may be the treatment of choice at first, although surgical techniques give somewhat better long-term results for pain relief. Extracorporeal shock wave lithotripsy, stone resolution or extraction and multiple pancreatic stents without aggressive balloon dilatation can progressively calibrate dominant stricture of the main pancreatic duct without further damage, ischemia or obstruction of side branches. Relapse-free period becomes longer (also after stents removal) if alcohol consumption and smoking are stopped definitively. Well-controlled, randomised studies are still needed to demonstrate clinical advantage of multiple endoscopic stent placement in comparison to surgery.

A Clinical Risk Score for Prediction of Stent Thrombosis

The aim was to develop a clinically useful patient risk score predictive for stent thrombosis (ST). Using readily available baseline clinical and angiographic characteristics, a Cox proportional hazards multivariate model was used to identify significant (p <0.10) predictors of ST through 1 year in 2,487 patients receiving a TAXUS Express (Boston Scientific Corp., Natick, Massachusetts) drug-eluting stent (DES) in the ARRIVE 1 registry. Hazard ratios of significant predictors were rounded to an integer value ranging from 2 to 5. These values were summed for a maximum possible score of 24. The model was validated using 1-year data from a similar DES data set (ARRIVE 2, n = 4,820 patients). The 8 significant predictors found were thienopyridine therapy discontinuation before 6 months, insulin-requiring diabetes, smoker at baseline, left main stent placement, multiple stent placement, lesion length >28 mm, moderate to severe lesion calcification, and reference vessel diameter <3 mm. Model discrimination was high, indicated by an area under the receiver-operator characteristic curve of 0.819. Stratification of patients into low-, medium-, and high-risk groups showed that ST developed in 0.8% of patients with a score <6, 3.6% of patients with a score of 7 to 13, and 12.6% of patients with a score >or=14. In conclusion, using 8 readily available clinical and angiographic characteristics, we defined an ST risk score for patients receiving a DES during the first year. Analysis of patients from ARRIVE 1 and 2 showed that most (73%) were in the lowest risk category, with 25% in the moderate risk category. Less than 2% were at highest risk of developing ST.

Very Late Stent Thrombosis After Dual Antiplatelet Therapy Discontinuation in a Patient with a History of Acute Stent Thrombosis

To describe a case of very late stent thrombosis after dual antiplatelet discontinuation in a patient with a previous history of stent thrombosis. A 62-year-old man with a history of coronary artery disease, multiple acute coronary syndromes requiring percutaneous coronary interventions with multiple stent placements, and acute stent thrombosis resulting in ST segment elevation myocardial infarction presented to the hospital with chest pain. The chest pain was not relieved by 4 sublingual nitroglycerin tablets. Five days prior to his presentation, the patient had been instructed to discontinue both aspirin and clopidogrel in preparation for a left ankle fusion procedure. He was taken to the cardiac catheterization laboratory where he was found to have thrombosis in a sirolimus-eluting stent placed more than 3 years ago. Thrombectomy and balloon angioplasty were performed, and the patient completed his hospital course without complications. Stent thrombosis associated with drug-eluting stents is a complicated pathophysiologic phenomenon with multiple patient-, procedure-, and device-related factors. Application of these risk factors to quantify the risk of stent thrombosis as they apply to a single patient is unknown. Discontinuation of recommended dual antiplatelet therapy with aspirin plus a thienopyridine has been identified as a major risk factor for stent thrombosis, but the optimal duration of dual antiplatelet therapy remains unknown. Current recommendations suggest extending dual antiplatelet therapy beyond one year in patients with low bleeding risk. Given the overall data at this time and the severity of stent thrombosis, it seems prudent to continue dual antiplatelet therapy with aspirin indefinitely plus a thienopyridine for at least one year, with continuation beyond one year on a case-by-case basis depending on the risks of in-stent thrombosis and bleeding. In patients with a low risk of bleeding, indefinite continuation of dual antiplatelet therapy may be reasonable.

Early Symptomatic Strictures after Gastric Surgery: Palliation with Balloon Dilation and Stent Placement

To evaluate the clinical efficacy and safety of balloon dilation and stent placement in the treatment of early benign anastomotic strictures after gastric surgery. From 1997 to 2006, 63 patients with early (< or =3 months) benign anastomotic strictures after gastric surgery underwent fluoroscopic balloon dilation or stent placement due to obstructive symptoms. In all patients, balloon dilation was initially performed. Stent placement was indicated in patients who showed poor response to repeat balloon dilation. Balloon dilations were successfully performed in all 63 patients, with only three intramural tears. Thirty-one of the 63 patients (49%) showed good response to initial balloon dilation and required no further treatment until the end of follow-up or death. Conversely, 32 patients (51%) had poor or no response or recurrence after initial balloon dilation and required multiple balloon dilations (n = 20), stent placement (n = 7), percutaneous gastrojejunostomy (n = 2), and/or surgical revision (n = 3). At multivariate analysis, the anastomotic site was the only independent factor predictive of the response to balloon therapy (P < .001). During a mean follow-up of 12 months, overall clinical success was achieved in 56 of the 63 patients (89%) after a single balloon dilation (n = 31), multiple balloon dilations (n = 20), and stent placement (n = 5). Balloon dilation is safe and effective for the treatment of patients with early benign anastomotic strictures after gastric surgery. Stent placement can be effective in selected patients with early benign anastomotic strictures refractory to balloon dilation.

Rapid-sequence endoscopic management of posttransplant anastomotic biliary strictures

Post-liver-transplant anastomotic biliary strictures generally have been managed through ERCP with gradual balloon dilation and placement of multiple stents over an extended period of time. Our purpose was to evaluate the long-term outcome of rapid sequence dilation and to shorten the duration of stenting as a therapy for anastomotic biliary strictures. Prospective case series. Academic tertiary referral center. ERCP with rapid-sequence balloon dilation of post-liver-transplant anastomotic biliary strictures followed by stenting with multiple stents over a short time period. Long-term anastomotic stricture resolution. Thirty-eight patients were prospectively enrolled into a standardized ERCP treatment protocol. The mean number of ERCPs per patient was 3.4 (range 2-6), the mean number of maximum stents inserted was 2.5 (range 1-6), and the mean total stenting period was 107 days (range 20-198 days); the mean follow-up time from completion of the endoscopic therapy was 360 days (range 140-1347 days). Long-term stricture resolution was achieved in 33 of the 38 (87%) patients. Lack of control group, relatively small patient population. Accelerated dilation and shorter total length of stenting leads to long-term success in the majority of patients with post-liver-transplant anastomotic biliary strictures.

Diagnosis of autoimmune pancreatitis with intraductal biliary biopsy and treatment of stricture with serial placement of multiple biliary stents

Diagnosis of autoimmune pancreatitis with intraductal biliary biopsy and treatment of stricture with serial placement of multiple biliary stents

Endoscopic treatment of biliary complications after liver transplantation

To evaluate the efficacy of endoscopic treatment in patients who undergo OLTx or LRLTx and develop biliary complications. This is a prospective, observational study of patients who developed biliary complications, after OLTx and LRLTx, with duct-to-duct anastomosis performed between June 2003 and June 2007. Endoscopic Retrograde Cholangiopancreatography (ERCP) was considered unsuccessful when there was evidence of continuous bile leakage despite endoscopic stent placement, or persistence of stenosis after 1 year, despite multiple dilatation and stent placement. When the ERCP failed, a percutaneous trans-hepatic approach (PTC) or surgery was adopted. From June 2003 to June 2007, 261 adult patients were transplanted in our institute, 68 from living donors and 193 from cadaveric donors. In the OLTx group the rate of complications was 37.3%, while in the LRLTx group was 64.7%. The rate of ERCP failure was 19.4% in the OLTx group and 38.6% in LRLTx group. In OLTx group, 1 patient was re-transplanted and 8 patients died. In the LRLTx group, 2 patients underwent OLTx and 8 patients died. The follow-up was 23.3 +/- 13.13 mo and 21.02 +/- 14.10 mo, respectively. Although ERCP is quite an effective mode of managing post-transplant bile duct complications, a significant number of patients need other types of approach. Further prospective studies are necessary in order to establish whether other endoscopic protocols or new devices, could improve the current results.

QUANTIFICATION OF HEMODYNAMIC CHANGES INDUCED BY VIRTUAL PLACEMENT OF MULTIPLE STENTS ACROSS A WIDE-NECKED BASILAR TRUNK ANEURYSM

The porous intravascular stents that are currently available may not cause complete aneurysm thrombosis and may therefore fail to provide durable protection against aneurysm rupture when used as a sole treatment modality. The goal of this study was to quantify the effects of porous stents on aneurysm hemodynamics using computational fluid dynamics. The geometry of a wide-necked saccular basilar trunk aneurysm was reconstructed from a patient's computed tomographic angiography images. Three commercial stents (Neuroform2; Boston Scientific/Target, San Leandro, CA; Wingspan; Boston Scientific, Fremont, CA; and Vision; Guidant Corp., Santa Clara, CA) were modeled. Various combinations of one to three stents were virtually conformed to fit into the vessel lumen and placed across the aneurysm orifice. An unstented aneurysm served as a control. Computational fluid dynamics analysis was performed to calculate the hemodynamic parameters considered important in aneurysm pathogenesis and thrombosis for each of the models. The complex flow pattern observed in the unstented aneurysm was suppressed by stenting. Stent placement lowered the wall shear stress in the aneurysm, and this effect was increased by additional stent deployment. Turnover time was moderately increased after single- and double-stent placement and markedly increased after three stents were placed. The influence of stent design on hemodynamic parameters was more significant in double-stented models than in other models. Aneurysm hemodynamic parameters were significantly modified by placement of multiple stents. Because the associated modifications may be helpful as well as harmful in terms of rupture risk, use of this technique requires careful consideration.

Risk of pancreatitis following endoscopically placed large-bore plastic biliary stents with and without biliary sphincterotomy for management of postoperative bile leaks

Endoscopic transpapillary biliary stent placement is effective for closure of postoperative bile leaks. Large-bore stents (10 French) may transiently obstruct the adjacent pancreatic duct orifice causing acute pancreatitis. Endoscopic biliary sphincterotomy may reduce this risk, but it introduces separate risks of bleeding and perforation. The objective of this study was to compare complications after large-bore biliary stent placement (10 Fr) with and without sphincterotomy in patients with bile leaks. The institutional endoscopy database was queried to identify patients who had undergone endoscopic retrograde cholangiopancreatogrpahy (ERCP) for bile leak between March 1996 and August 2006. Procedural reports were reviewed for evidence of biliary sphincterotomy, cholangiographic and pancreatographic findings, transpapillary stent placement, and procedural complications. Patients with prior biliary sphincterotomy, choledochoenteric anastomosis, placement of multiple biliary stents and expandable metal biliary stents, biliary stents smaller than 10 Fr, and patients in whom a stent was not placed were excluded. The chi-square test was used for categorical variables. Probability <or= 0.05 was considered significant. The rate of pancreatitis (all mild) after large-bore biliary stent placement was greater when sphincterotomy was not performed than when sphincterotomy and stent placement were both performed (13% versus 2.4%). This difference was not statistically significant. (Chi(2) = 3.41; p = 0.1). Bleeding was observed in one patient who underwent sphincterotomy and large-bore stent placement (2.4%). No perforations occurred in either group. Although not statistically significant, there is a higher rate of post-ERCP pancreatitis after placement of large-bore biliary stents when sphincterotomy is not performed. The additional complications of biliary sphincterotomy did not offset the reduction in post-ERCP pancreatitis. When large-bore biliary stents are used in the treatment of bile leak, a biliary sphincterotomy may avoid pancreatitis. Randomized trials are needed to determine whether there is a significant difference in overall complication rate when large-bore stents are placed with and without biliary sphincterotomy.

Analysis of the placement of multiple metallic stents in the treatment of hilar cholangiocarcinoma

目的 探讨应用金属内支架治疗复杂型肝门部胆管癌,特别是侵犯肝内胆管的肝门部胆管癌的介入治疗方法 .方法 肝门部胆管癌45例,其中BismuthⅡ型12例、Ⅲa型17例、Ⅲb型10例、Ⅳ型6例.45例均先行经皮经肝胆管引流术后实施胆管内支架置入术,分别以T、Y、X型或其组合方式留置2或3枚内支架.结果 45例患者内支架96枚全部置入成功,治疗后胆红素[(312±249)μmol/L]与治疗前[(51±42)μmol/L]相比明显下降(t=4.21,P＜0.01),支架置入后30 d内病死率为2.2%(1/45).平均支架开通时间181.5 d(26～473 d),平均生存时间215.3 d(26～516 d).结论 对于复杂型肝门部胆管癌,胆管内支架治疗是一种有效改善患者生存质量的方法 .特别对病变侵犯肝内胆管的病例,应选择不同的穿刺路径及支架留置方法 ,尽可能解决更多肝段的胆管引流。

Selective MRCP and CT-Guided Drainage of Malignant Hilar Biliary Obstruction

Hilar tumors represent a complex disease process with potentially poor outcomes. Curative options in patients with hilar tumors are limited. Successful palliation by providing effective drainage is often the principal intervention, and success can offer substantial improvement in quality of life. Their complexity and location make hilar tumors challenging for the endoscopist. The traditional approach of opacifying the entire biliary tract with contrast increases the risk of infectious complications or requires placement of multiple stents, which is often not feasible. Computed tomography (CT) scan and magnetic resonance cholangiopancreatography (MRCP) with reconstructed images are essential noninvasive tools that provide an excellent roadmap of hilar tumors. The information provided can help in guiding the endoscopist to selectively access the optimal intercommunicating ducts for opacification and drainage. In this review, we discuss the approach to endoscopic retrograde cholangiography in hilar tumors, including use of CT scan and MRCP to aid with selective access and stenting. Intrahepatic duct access is done primarily with guidewires and limited use of contrast material. In general, unilateral placement of a metallic stent is adequate, but in select circumstances, bilateral stents may be required. The approach of targeted drainage appears to decrease complications arising from endoscopic drainage of hilar tumors and allows for effective palliation in most circumstances.

Endoscopic treatment of anastomotic biliary strictures after deceased donor liver transplantation: outcomes after maximal stent therapy

The optimal endoscopic treatment for anastomotic biliary strictures after deceased donor liver transplantation is undefined. Endoscopic therapy with conventional methods of biliary dilation and stent placement has been successful but often requires prolonged therapy. To determine the outcomes of an aggressive endoscopic approach that uses endoscopic dilation followed by maximal stent placement. Tertiary-care academic medical center. Of 176 patients who underwent deceased donor liver transplantation between June 1999 and July 2004, 25 were diagnosed with anastomotic biliary strictures. Patients were treated endoscopically with a combined technique of balloon dilation and maximal stent placement. Treatment outcomes, including bile-duct patency, a need for surgical intervention, morbidity, and mortality, were evaluated retrospectively. Endoscopic dilation followed by maximal stent placement was performed until resolution of strictures in 22 of 25 patients (88% immediate success on intent-to-treat analysis). Persistent resolution of strictures was achieved in 18 of these 22 patients. Re-treatment was successful in 2 of 4 patients with recurrent strictures. Overall, 20 of 22 patients who completed endoscopic therapy (91%) avoided surgical intervention. Median duration of endoscopic treatment was 4.6 months. Patients with early onset strictures required a significantly shorter duration of endoscopic therapy (3 vs 9 months; P<.01). Multiple stent placement was not technically difficult, and no major complications were encountered. Aggressive endoscopic therapy with combined biliary dilation and maximal stent placement allows resolution of anastomotic biliary strictures after deceased donor liver transplantation in a relatively short period, with sustained success and minimal complications.

Placement of Multiple Metallic Stents Before Gemcitabine Therapy Is Safe and Effective in the Treatment of the Patients with Hilar Biliary Stenosis Caused By Biliary Tract Carcinoma

Aim: The management of bile duct stenosis is important before chemotherapy of biliary tract carcinoma. The aim of this study was to assess whether gemcitabine (GEM) chemotherapy is safe and effective for the biliary tract carcinoma after placement of multiple metallic stents (MS). Methods: Between March, 2003 and October, 2006, 11 patients (2 females and 9 males, mean age of 64 years) with unresectable biliary tract carcinoma were treated with GEM after placement of multiple MS due to hilar biliary stenosis. GEM 1,000 mg/m2 was administerd intravenously 30-min on the day 1, 8 and 15 for every 28 days. All the patients had JOSTENT Selfx inserted via endoscopic route. The stents were deployed in partial stent-in-stent procedure (Y-shape). The mean follow-up period was 256 days. All time-to-event measures were calculated using the Kaplan-Meier method. Results:The diagnoses were cholangiocarcinoma (N = 8), gallbladder carcinoma (N = 3). According to the Bismuth classification, 1 patient had type 2, 1 had type 3a, and 9 had type 4. The partial response was achieved in 2 patients (18.2%), stable disease in 7 (63.6%), and progressive disease in 2 (18.2%). The median survival time was 444 days and the median progression-free interval was 196 days. No grade 4 toxicity was seen. Transient grade 3 neutropenia/thrombocytonenia 4 (36%) were the most common toxicity. The biliary complications were observed in 6 (54.5%) patients, and the median complication-free interval wad 175 days. Stent occlusion occurred in 4 patients (sludge in 2, tumor ingrowth in 2), cholecystitis in 1, and hemobilia in 1. The patients were successfully recovered from these complications by the interventional radiology or endoscopic therapy. Cholecystitis was treated with percutaneous transhepatic gallbladder drainage, and hemobilia was treated with transcatheter arterial embolization. The remaining patients were all treated with endoscopic therapy. The plastic tube stent were inserted into the lumen of the previous deployed MS. The sludge was cleared by retrieval balloon. The number of intervention after insertion of MS was none in 5 patients, once in 4, and three times in 2. Conclusion:Multiple MS placement before chemotherapy of biliary tract carcinoma is safe and effective.

Endoscopic Ultrasound Guided Transmural Debridement of Organized Pancreatic Necrosis: A Retrospective Cohort Study

Introduction: Pancreatic necrosis is a severe complication of acute pancreatitis. Surgery has been the mainstay of treatment once intervention was necessary. Surgical management is however associated with significant morbidity and mortality. By the time necrosis becomes organized endoscopic therapy has the potential to offer an alternative treatment. However, due to rapid blockage of stent or naso-cystic catheter by necrotic material, endoscopic drainage of pancreatic necrosis is often considered contraindicated. This could be overcome by adding endoscopic debridement to transmural drainage. We have performed a retrospective study on our prospectively collected cohort of patients evaluating the results and complications with this new technique. Aim was to evaluate its safety and efficacy and to identify procedural aspects that may improve outcome. Patients and Methods: All consecutive patients who underwent endoscopic debridement of pancreatic necrosis in our hospital between January 2003 and July 2006 were included. In all patients the treatment was started with EUS-guided transmural drainage of the collection with placement of multiple stents and naso-cystic catheter. The next step consisted of balloon dilatation up to 18 mm, advancement of an endoscope into the retroperitoneal cavity and endoscopic debridement of the collection under direct vision. Endoscopic debridement was repeated every 2 days until most necrotic material was evacuated. Additionally, naso-cystic catheter irrigation was performed manually with saline 6-8 times a day. The endpoint of treatment was complete resolution of the necrotic collection and related symptoms. Results: 25 patients (13 women, 12 men) were identified, who had undergone debridement of 27 collections. After the initial stent placement, in eleven collections (41%) one, in 13 (48%) two, in 2 (7%) three and 1 (4%) four endoscopic debridement procedure(s) were performed. There was no mortality. Severe complications occurred in 2 patients (7%) and required surgery: Hemorrhage in one case and perforation of cyst wall in the other. During a median follow up of 16 (range 3-38) months, the overall clinical success rate with resolution of the collection and related symptoms was 93%. Two patients (7%) developed an asymptomatic recurrent pseudocyst of 5.6 and 3 cm. Conclusion: In this study we have shown that endoscopic debridement is an effective and relatively safe minimally invasive therapy in patients with symptomatic organized pancreatic necrosis. Further comparative studies need to define its definitive role in the management of these patients.

New Endoscopic Technique for Multiple Plastic Stent Placements in the Common Bile Duct (CBD) Without the Need for Recannulation, Utilizing a Special Loop Tip Wire Guide (LTWG) and a New Loop On Loop Technique (LOL)

Currently, there are several endoscopic techniques that allow for multiple plastic stent placements in the CBD without having to regain ductal access through the stricture, which can involve the use of at least one 480 cm. wire guide. When using this technique, difficulties occur when there is a need to place more than two stents through the narrow space of the stricture that is presently occupied by the wire guide and the prostheses. This can lead to the failure of the procedure. Objective: The Loop Tip Wire Guide (Cook Company) is a new wire guide with a loop at the distal flexible end of the device that allows for the passage through strictures, irregular surfaces, and avoids the formation of false tracks.