Placement Of Multiple Plastic Stents Research Articles

Tuberculosis biliary stricture simulating as cholangiocarcinoma.

Tuberculosis (TB) is a rare cause of biliary stricture that is difficult to diagnose preoperatively. Patient present with obstructive jaundice, which may be confused with hepatobiliary malignancies. Suspicion of the disease with knowledge and awareness and establishing tissue diagnosis along with advent of image guided FNAC, endoscopic brush cytology and PCR testing of bile, diagnosis of hepatobiliary TB can be made without the need of laparotomy. Biliary TB is a potentially curable condition when diagnosed preoperatively requiring antituberculosis therapy & avoiding surgery [1]. Surgery is most often required for relief of biliary obstruction [2]. Failure to obtain preoperative tissue diagnosis may lead to histological diagnosis of biliary TB only after major surgery. TB of lower end of common bile duct (CBD) and periampullary region often forms pseudotumour and strictures mimicking cholangio carcinoma [3]. Hepatobiliary TB may be caused by three ways: (1) Spread of caseous material from the portal tracts into the bile ducts (most often), (2) Secondary inflammation-related tuberculous periportal lymphadenitis, (3) Spread of caseous material through the ampulla of Vater and ascending along the CBD [4]. Benign biliary strictures fall into two etiological groups: Traumatic (Post operative, Blunt, or Penetrating injury) and Nontraumatic (Sclerosing cholangitis, Recurrent pyogenic cholangitis, Chronic pancreatitis, Mirizzi syndrome) [5]. Various other benign conditions are Eosinophilic granuloma, Duodenal papillitis, Infestations due to Ascaris lumbricoides and Clonorchis sinensis. Tuberculous biliary stricture is due to the secondary endo luminal inflammatory process and scarring. Tuberculous biliary stricture involves all parts of the biliary tree, but commonly involving CBD [6]. We came across five cases of Tubercular biliary stricture in last six years. All the patients had no specific clinical findings & there was lack of constitutional symptoms of TB such as fever and night sweat, absence of past history of TB, negative tuberculin skin test, lack of radiological evidence of old or active TB. CBD was involved with either stricture or pseudo tumour [Table/Fig-1]. [Table/Fig-1]: Findings of five cases in present study The factors like (1) a past history of TB, (2) other systemic manifestations like pulmonary or generalized lymph node involvement, (3) associated involvement of other abdominal organs, (4) mild jaundice, (5) abdominal pain more than an abdominal mass, (6) image guided FNAC or biopsy in suspected cases, and (7) the geographic area where the patient resides might help in differentiating biliary TB from biliary tract malignancy [7]. Preoperative diagnosis of TB as the cause of obstructive jaundice is extremely difficult often compelling major resectional surgery such as whipples pancreatoduodenectomy. In most of the cases, final diagnosis is reached in the postoperative period by the histological finding of caseation necrosis and epitheloid granuloma formation and Langhans giant cells [1]. All the patients in our study were put on ATT. Patients without surgery showed improvement and are on regular follow up. My research review on various documented articles reflects the need to diagnose this disguising condition with various available investigations keeping TB in mind [Table/Fig-2]. [Table/Fig-2]: Comparison of various published literature with the present study There are several proposed investigations for preoperative diagnosis, for example, detection of acid fast bacilli (AFB) after staining or culture in the biliary fluid aspirate during ERCP, FNAC, and frozen section [18]. PCR technique for Mycobacterium TB from biliary fluid is helpful because of its sentivity [6]. The tubercular biliary stricture can be cured with antitubercular medications with excellent prognosis. In few reported cases, the biliary stricture does not resolve with medical therapy alone and requires surgical intervention and biliary metallic stent placement [1]. Whipples pancreastoduodenectomy is done for distal CBD stricture and choledochoduodenostomy is required in multiple strictures. Sequential placement of multiple plastic stents has been shown to be effective, as the stents both enable biliary drainage and act as dilators [17] . Although favourable results can be achieved by medical therapy and with repeated stenting of the bile ducts, long-term follow-up is required due to the risk of post-treatment cicatricial stenosis [5] . If preoperative diagnosis is established, major surgery can be avoided, which increases morbidity and mortality. Patients presenting with a short history with relatively good health from tuberculosis endemic country like India, tubercular biliary stricture should be kept in mind as a differential diagnosis. These benign lesions should be differentiated from malignant masquerade, equally keeping in mind not to mistake malignant lesions for benign lesions.

Endoscopic Management of Biliary Leaks After Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy has become the procedure of choice for management of symptomatic cholelithiasis. Although it has distinct advantages over open cholecystectomy, bile leak is more common. Endoscopic retrograde cholangiopancreatography is the diagnostic and therapeutic modality of choice for management of postcholecystectomy bile leaks and has a high success rate with the placement of plastic biliary stents. Repeat endoscopic retrograde cholangiopancreatography with placement of multiple plastic stents, a covered metal stent, or possibly cyanoacrylate therapy may be effective in refractory cases. This review will discuss the indications, efficacy, and complications of endoscopic therapy.

Endoscopic treatment of post-liver transplantation anastomotic biliary stricture: systematic review and meta-analysis.

Biliary strictures after liver transplantation are recognized as its Achilles' heel. The strictures are classified in anastomotic and ischemic or non-anastomotic biliary strictures, and they figure among the most common complications after liver transplantation. There are some treatment options including balloon dilation, the placement of multiple plastic stents and the placement of self-expandable metal stents and all of them seem to have good results. The aim of this study was to systematically review the literature concerning the results of the endoscopic treatment of anastomotic biliary strictures after liver transplantation. A systematic review of the literature was performed on the management of anastomotic biliary strictures post- orthotopic liver transplantation. The Medline-PubMed, EMBASE, Scielo-LILACS, and Cochrane Databases were electronically searched from January 1966 to April 2013. No well-designed randomized controlled trial was found. Most studies were retrospective or prospective comparisons in design. One study (86 patients) compared the endoscopic and the percutaneous accesses. The sustained clinical success rates were similar but the treatment duration was longer in the percutaneous group access. Two studies (56 patients) compared balloon dilation with balloon dilation and multiple plastic stents. There were no differences concerning sustained clinical success and complication rates. Balloon dilation is as effective as balloon dilation plus multiple plastic stenting for the resolution of the anastomotic biliary strictures. Well-designed randomized trials are still needed to compare balloon dilation versus multiple plastic stenting versus metallic stenting.

734 Endoscopic Transmural Drainage of Pancreatic Pseudocysts: Multiple Plastic Stents Versus Metal Stents- a Systematic Review and Meta-Analysis

Endoscopic ultrasound (EUS)-guided transmural drainage of pancreatic pseudocysts by using multiple plastic or fully covered self-expandable metal stents (FCSEMSs) is well-established. The placement of multiple plastic stents (MPSs) can be technically difficult and tedious because of the need to access the cyst cavity multiple times. FCSEMSs have been proposed to circumvent the need for multiple accesses. However, it is not clear whether there are definite advantages of using FCSEMSs over MPSs. Our aim was to compare the efficacy and safety of MPSs and FCSEMSs in transmural drainage of pancreatic pseudocysts.

Metal Stenting in Benign Biliary Strictures

Metal Stenting in Benign Biliary Strictures

Predictive value of cholangioscopy after endoscopic management of early postcholecystectomy bile duct strictures with an increasing number of plastic stents: a prospective study (with videos)

Endotherapy of postcholecystectomy bile duct stricture (PCBS) has been established as an alternative treatment to surgery. Several studies have reported conflicting results regarding the predictors of success or failure of endotherapy. To evaluate the different cholangioscopic appearances of PCBS after endotherapy with an increasing number of plastic stents and the predictive values of these appearances for the outcome. Prospective study with a long-term follow-up. Two academic tertiary referral centers. Twenty consecutive patients with major bile duct injury, with a bile leak, and a PCBS who underwent therapeutic ERCP. Closure of the leak followed by temporary placement of multiple plastic stents for the treatment of PCBS, followed by cholangioscopy at the end of endotherapy. To analyze the predictive value of cholangioscopy, other predictors of stricture recurrence after endotherapy, and long-term clinical success. Closure of the leak was achieved in all patients. The median duration of endotherapy was 12 months (range 7-18 months). After endoscopic stenting, the PCBS was considered to be appropriately dilated in all patients. After endotherapy, 3 different findings were noted on cholangioscopy: (1) no lesion or minor defect (n = 10), (2) minor stricture with a fibrous ring (n = 6), and (3) presence of tissue hyperplasia (n = 4). During follow-up, stricture recurrence developed in 4 of 20 patients. All 4 patients were successfully retreated by an additional period of stenting and remained free of cholestasis after a median follow-up period of 44 months. By Kaplan-Meier (log-rank) and univariate analyses, the cholangioscopic pattern of tissue hyperplasia was significantly associated with stricture recurrence (P < .01). Small sample size. Endoscopic stenting should be regarded as the primary treatment of choice because of the successful long-term outcome after 1 or more additional periods of treatment. However, the cholangioscopic pattern of tissue hyperplasia at the time of stent removal is a strong predictor of stricture recurrence, and this observation may lead to an additional period of endotherapy or other treatment modalities.

Su1429 A Fully Covered Self-Expandable Metal Stent, Niti-S, for Benign Biliary Strictures: a Prospective Multi-Center Follow-up Study

Treatment of benign biliary stricture (BBS) generally consists of sequential placement of multiple plastic stents. A major drawback of this approach is the need for frequent stent exchange. Self-expandable metal stents (SEMS) are increasingly being used as an alternative because of their larger diameter. The use of fully covered SEMS enables easy stent removal; however, there is a risk of stent migration due to a lower anchoring capacity. The Niti-S is a fully covered SEMS with flared ends to prevent migration.

ENDOSCOPIC TREATMENT FOR BILIARY STRICTURE SECONDARY TO CHRONIC PANCREATITIS

The causes of benign biliary stricture include chronic pancreatitis, primary/immunoglobulin G4-related sclerosing cholangitis and complications of surgical procedures. Biliary stricture due to fibrosis as a result of inflammation is sometimes encountered in patients with chronic pancreatitis. Frey's procedure, which can provide pancreatic duct drainage with decompression of biliary stricture, can be an initial treatment for chronic pancreatitis with pancreatic and bile duct strictures with upstream dilation. When patients are high-risk surgical candidates or hesitate to undergo surgery, endoscopic treatment appears to be a potential second-line therapy. Placement of multiple plastic stents is currently considered to be the best choice as endoscopic treatment for biliary stricture due to chronic pancreatitis. Temporary placement with a fully covered metal stent has become an attractive option due to the lesser number of endoscopic retrograde cholangiopancreatography (ERCP) sessions and its large diameter. Further clinical trials comparing multiple placement of plastic stents with placement of a covered metal stent for biliary stricture secondary to chronic pancreatitis are awaited.

Single-step endoscopic ultrasonography-guided drainage of peripancreatic fluid collections with a single self-expandable metal stent and standard linear echoendoscope

Endoscopic ultrasonography (EUS)-guided drainage of peripancreatic fluid collections (PFCs) is a well described alternative to surgery or percutaneous drainage. However, it is limited by the requirement for a large working channel that allows multiple plastic stent placement, which is only commercially available on therapeutic linear echoendoscopes. Herein, we describe the drainage of PFCs with a single self-expandable metal stent (SEMS) using a single-step technique and standard linear echoendoscope. Seven cases were identified during a retrospective chart review, and included all patients who had undergone EUS-guided drainage of PFCs during a 6-month period. The mean age was 46 years (range 25 - 70 years) and all patients were symptomatic. The mean diameter of PFCs was 8 cm (range 4.1 - 12.5 cm). Previous percutaneous drainage had failed in three patients. A total of 10 PFCs were drained. Three patients had two cysts drained by the same stent and one patient had two separate procedures to drain two distinct cysts. The SEMS was in place for a mean of 13 weeks (range 4 - 34 weeks). Successful placement of SEMS was achieved in all seven cases. Patients were followed for a mean of 18 weeks (range 7 - 35 weeks), and symptom improvement was achieved in all cases. Complete resolution of PFC was achieved in 9 /10 cysts. No complications were encountered. Single-step EUS-guided drainage of PFCs using a single 10-mm SEMS and a standard linear echoendoscope appears to be a feasible endoscopic technique with excellent technical and clinical success rates.

Role of Fully Covered Self-Expandable Metal Stent for Treatment of Benign Biliary Strictures and Bile Leaks

Endoscopic therapy by balloon dilation and placement of multiple large-bore plastic stents is the treatment of choice for benign biliary stricture. This approach is effective but it typically requires multiple endoscopic sessions given the short duration of stent patency. The endoscopic approach for treatment of bile leak involves the placement of a stent with or without biliary sphincterotomy. The self-expandable metal stent (SEMS) has traditionally been used for palliation of malignant biliary strictures given the long duration of stent patency owing to their larger stent diameter. Recently, SEMS has been used in a variety of benign biliary strictures and leaks, especially with the design of the covered self-expandable metal stent (CSEMS), which permits endoscopic-mediated stent removal. The use of CSEMS in benign biliary stricture could potentially result in a decrease in endoscopic sessions and it is technically easier when compared to placement of multiple plastic stents. However, complications such as cholecystitis due to blockage of cystic duct, stent migration, infection and pancreatitis have been reported. The potential subsegmental occlusion of contralateral intrahepatic ducts also limits the use of CSEMS in hilar stricture. Certain techniques and improvement of stent design may overcome these challenges in the future. Thus, CSEMS may be appropriate in only highly selected conditions, such as refractory benign biliary stricture, despite multiple plastic stent placement or difficult to treat bile duct stricture from chronic pancreatitis, and should not be used routinely. This review focuses on the use of fully covered self-expandable metal stent for benign biliary strictures and bile leaks.

Endoscopic biliary recanalization by using a needle catheter in patients with complete ligation or stricture of the bile duct: safety and feasibility of a novel technique (with videos)

Benign bile duct strictures involving the extrahepatic biliary tree can pose a therapeutic challenge. Occurrence of such strictures is well-recognized in patients after liver transplantation at the site of duct-to-duct anastomoses, in cases of ischemic injury to the bile duct, and after inadvertent ligation or injury to the bile duct during cholecystectomy. 1 Parmeggiani D. Cimmino G. Cerbone D. et al. Biliary tract injuries during laparoscopic cholecystectomy: three case reports and literature review. G Chir. 2010; 31: 16-19 PubMed Google Scholar , 2 Safdar K. Atiq M. Stewart C. et al. Biliary tract complications after liver transplantation. Expert Rev Gastroenterol Hepatol. 2009; 3: 183-195 Crossref PubMed Scopus (14) Google Scholar Although conventional treatment includes surgical hepaticojejunostomy or, in the past, percutaneous dilation and stenting, there is increasing evidence for and acceptance of treatment of such strictures via ERCP. 3 Vitale G.C. Tran T.C. Davis B.R. et al. Endoscopic management of postcholecystectomy bile duct strictures. J Am Coll Surg. 2008; 206 (discussion 24-5): 918-923 Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar At ERCP, a guidewire is passed through the stricture into the intrahepatic ducts. The stricture is subsequently treated with placement of multiple plastic stents (7F, 8.5F, or 10F), with increasing data indicating that the best long-term outcomes are achieved by multiple, large-bore stents left in for a long duration (1 year). 4 Costamagna G. Pandolfi M. Mutignani M. et al. Long-term results of endoscopic management of postoperative bile duct strictures with increasing numbers of stents. Gastrointest Endosc. 2001; 54: 162-168 Abstract Full Text Full Text PDF PubMed Scopus (357) Google Scholar The stents usually are placed after dilation of the stricture, but in some cases dilation may not be necessary. There have been case reports describing placement of fully or partially covered metal stents for such strictures. 5 Tee H.P. James M.W. Kaffes A.J. Placement of removable metal biliary stent in post-orthotopic liver transplantation anastomotic stricture. World J Gastroenterol. 2010; 16: 3597-3600 Crossref PubMed Scopus (35) Google Scholar To be feasible, however, endoscopic therapy requires traversing the stricture with a guidewire. In some patients with very high-grade strictures or complete ligation of the bile duct, a guidewire cannot be passed through the stenosis, and no contrast material can be forced upstream. Such patients generally have been precluded from endoscopic or percutaneous therapy and have been treated with surgical intervention involving a Roux-en-Y hepaticojejunostomy. As an alternative to endoscopic recanalization, percutaneous access to the upstream duct and a subsequent attempt at ERCP rendezvous for recanalization has been reported. 6 Dowsett J.F. Vaira D. Hatfield A.R. et al. Endoscopic biliary therapy using the combined percutaneous and endoscopic technique. Gastroenterology. 1989; 96: 1180-1186 Abstract PubMed Google Scholar However, there are no prior case series of endoscopic recanalization of a completely disconnected or ligated bile duct stricture. Previously we reported a case using this technique and placement of plastic stents. 7 Artifon E. Lopes T. da Silveira E. et al. Endoscopic recanalization following accidental ligation of the common hepatic duct A new technique. Rev Gastroenterol Mex. 2010; 75: 191-194 PubMed Google Scholar In this prospective series we describe safety and feasibility of this novel technique for recanalization and subsequent endoscopic therapy of completely occluded or ligated bile duct strictures by placement of a partially covered, self-expandable metallic stent (SEMS).

347e: Temporary Placement of Covered Self-Expandable Metal Stents (CSEMS) in Benign Biliary Strictures (BBS): Eight Years of Experience

Benign biliary strictures (BBS) have been endoscopically managed with placement of multiple plastic stents. Uncovered metal stents have been associated with mucosal hyperplasia and long term data on covered self-expandable metal stents (CSEMS) are still lacking in BBS. We report the efficacy and complication rates of CSEMS in the treatment of BBS.

Plastic or metal stents for benign extrahepatic biliary strictures: a systematic review

BackgroundBenign biliary strictures may be a consequence of surgical procedures, chronic pancreatitis or iatrogenic injuries to the ampulla. Stents are increasingly being used for this indication, however it is not completely clear which stent type should be preferred.MethodsA systematic review on stent placement for benign extrahepatic biliary strictures was performed after searching PubMed and EMBASE databases. Data were pooled and evaluated for technical success, clinical success and complications.ResultsIn total, 47 studies (1116 patients) on outcome of stent placement were identified. No randomized controlled trials (RCTs), one non-randomized comparative studies and 46 case series were found. Technical success was 98,9% for uncovered self-expandable metal stents (uSEMS), 94,8% for single plastic stents and 94,0% for multiple plastic stents. Overall clinical success rate was highest for placement of multiple plastic stents (94,3%) followed by uSEMS (79,5%) and single plastic stents (59.6%). Complications occurred more frequently with uSEMS (39.5%) compared with single plastic stents (36.0%) and multiple plastic stents (20,3%).ConclusionBased on clinical success and risk of complications, placement of multiple plastic stents is currently the best choice. The evolving role of cSEMS placement as a more patient friendly and cost effective treatment for benign biliary strictures needs further elucidation. There is a need for RCTs comparing different stent types for this indication.

Temporary placement of fully covered self-expandable metal stents in benign biliary strictures: midterm evaluation (with video)

Benign biliary strictures (BBS) have been endoscopically managed with placement of multiple plastic stents. Uncovered metal stents have been associated with mucosal hyperplasia and partially covered self-expandable metal stents with migration. Recently, fully covered self-expandable metal stents (CSEMSs) with anchoring fins have become available. Our purpose was to analyze the efficacy and complication rates of CSEMSs in the treatment of BBS. CSEMSs (10-mm diameter) were placed in 44 patients with BBS. CSEMSs were left in place until adequate biliary drainage was achieved, confirmed by resolution of symptoms, normalization of liver function tests, and imaging. Tertiary care center with long-standing experience with metal stents. A total of 44 patients with BBS (28 men, median age 53.5 years) were included. The preprocedure diagnoses included chronic pancreatitis (n = 19), gallstone-related strictures (n = 14), post liver transplant (n = 9), autoimmune pancreatitis (n = 1), and primary sclerosing cholangitis (n = 1). ERCP with temporary CSEMS placement. Removal of CSEMSs was performed with a snare or rat tooth. Stricture resolution and morbidity. The median time of CSEMS placement was 3.3 months (interquartile range 3.0-4.8). Resolution of the BBS was confirmed in 34 of 41 patients (83%) after a median postremoval follow-up time of 3.8 months (interquartile range 1.2-7.7). Complications were observed in 6 (14%) patients after CSEMS placement and in 4 (9%) after CSEMS removal. Pilot study from a single center. Temporary placement of CSEMSs for BBS may offer an alternative to plastic stenting. Further investigation is required to further assess safety and long-term efficacy.

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.

Multiple Stenting of Refractory Pancreatic Duct Strictures in Severe Chronic Pancreatitis: Long-term Results

Dominant pancreatic duct strictures located in the head of the pancreas in patients with severe chronic pancreatitis are often managed by endoscopic placement of a single plastic stent. Patients with refractory strictures after prolonged stenting require repeated stent replacement or surgical pancreaticojejunostomy. Placement of multiple plastic stents has proved effective in managing postoperative biliary strictures. The aim of this study was to investigate the feasibility, efficacy, and long-term results of multiple stenting of refractory pancreatic strictures in severe chronic pancreatitis. 19 patients with severe chronic pancreatitis (16 men, three women; mean age 45 years) and with a single pancreatic stent through a refractory dominant stricture in the pancreatic head underwent the following protocol: (i) removal of the single pancreatic stent; (ii) balloon dilation of the stricture; (iii) insertion of the maximum number of stents allowed by the stricture tightness and the pancreatic duct diameter; and (iv) removal of stents after 6 to 12 months. The median number of stents placed through the major or minor papilla was 3, with diameters ranging from 8.5 to 11.5 Fr and length from 4 to 7 cm. Only one patient (5.5 %) had persistent stricture after multiple stenting. During a mean follow-up of 38 months after removal, 84 % of patients were asymptomatic, and 10.5 % had symptomatic stricture recurrence. No major complications were recorded. Endoscopic multiple stenting of dominant pancreatic duct strictures in chronic pancreatitis is a feasible and safe technique. Multiple pancreatic stenting is promising in obtaining persistent stricture dilation on long-term follow-up in the setting of severe chronic pancreatitis.

Endoscopic stenting

Endoscopic management of postcholecystectomy biliary leaks is widely accepted as the treatment of choice. However, refractory biliary leaks after a combination of biliary sphincterotomy and the placement of a large-bore (10F) plastic stent can occur, and the optimal rescue endotherapy for this situation is unclear.To compare the clinical effectiveness of the use of a fully covered self-expandable metal stent (FCSEMS) with the placement of multiple plastic stents (MPS) for the treatment of postcholecystectomy refractory biliary leaks.Prospective study.Two tertiary-care referral academic centers and one general district hospital.Forty consecutive patients with refractory biliary leaks who underwent endoscopic management.Temporary placement of MPS (n = 20) or FCSEMSs (n = 20).Clinical outcomes of endotherapy as well as the technical success, adverse events, need for reinterventions, and prognostic factors for clinical success.Endotherapy was possible in all patients. After endotherapy, closure of the leak was accomplished in 13 patients (65%) who received MPS and in 20 patients (100%) who received FCSEMSs (P = .004). The Kaplan-Meier (log-rank) leak-free survival analysis showed a statistically significant difference between the 2 patient populations (χ2 [1] = 8.30; P < .01) in favor of the FCSEMS group. Use of <3 plastic stents (P = .024), a plastic stent diameter <20F (P = .006), and a high-grade biliary leak (P = .015) were shown to be significant predictors of treatment failure with MPS. The 7 patients in whom placement of MPS failed were retreated with FCSEMSs, resulting in closure of the leaks in all cases.Non-randomized design.In our series, the results of the temporary placement of FCSEMSs for postcholecystectomy refractory biliary leaks were superior to those from the use of MPS. A randomized study is needed to confirm our results before further recommendations.