Placement Of Multiple Stents Research Articles

When Should We Perform Endoscopic Drainage and Necrosectomy for Walled-Off Necrosis?

Endoscopic drainage and necrosectomy are now accepted treatment approaches for patients with symptomatic walled-off pancreatic necrosis (WON). The current recommendations advocate step-up approaches for the treatment of symptomatic WON. Previous recommendations stipulated that endoscopic intervention should be delayed until more than four weeks after the onset. Recent data on early drainage have been increasing and this option might be considered in well-encapsulated cases, but the percutaneous route is preferred if the drainage is performed within two weeks after onset or in nonencapsulated cases. Recently, additional drainage methods, such as the multiple gateway technique and multiple stent placement, have been developed to open up multiple dead spaces in the WON cavity. Endoscopic necrosectomy could be performed via the transluminal route or percutaneous route after failed initial and additional drainage procedures. The use of novel lumen-apposing stents is a promising treatment option that could reduce the number of steps, the procedure time, and the overall number of necrosectomies.

The placement of multiple plastic stents still has important roles in candidates for chemotherapy for unresectable perihilar cholangiocarcinoma.

Placement of uncovered self-expandable metallic stents (U-SEMSs) of patients with unresectable perihilar cholangiocarcinoma (UPHC) is recommended as the treatment of first choice to address bile stasis. The aim of this study was to determine which of the following two endoscopic stents might be the stent of first choice for the treatment of biliary stasis in patients with UPHC: plastic stents (PSs) or U-SEMSs. U-SEMSs, deployed as a stent-in-stent, were selected as the stents of first choice from 2013 and 2014, while PSs began to be selected as the stents of first choice from 2015 onward. The median time to recurrent biliary obstruction were 66days in the PS group (N=38) and 105days in the U-SEMS group (N=37; P=.04). Emergency endoscopy was necessitated in 76.3% (29/38) of patients of the PS group and 54.1% (20/37) of patients of the U-SEMS group (P=.0434). The success rate of the first reintervention was 96.5% (27/29) in the PS group and 55% (11/20) in the U-SEMS group (P=.0002). Sustainable chemotherapy could be carried out in 55.2% of patients in the PS group and 32.4% of patients in the U-SEMS group (P=.0472). Multivariate analysis identified selection of U-SEMS as the stent of first choice as the only independent factor predictive of successful reintervention (P=.0016, odds ratio=0.058). However, the stent selection was not an independent factor for feasible chemotherapy. Plastic stent placement could enhance the success rate of reintervention in patients with UPHC and might be facilitated by sustainable chemotherapy. However, stent selection might not have an influence on the prognosis.

Su1575 DISTAL BILIARY STENT MIGRATION IN PATIENTS WITH IRRETRIEVABLE COMMON BILE DUCT STONES: A RETROSPECTIVE COMPARISON BETWEEN STRAIGHT AND DOUBLE-PIGTAIL STENTS

Migration of biliary stents is a well-documented problem. Different types of plastic stents (straight or double-pigtail) are used for biliary drainage in patients with irretrievable common bile duct stones (ICBDS). Due to their physical characteristics, double-pigtail stents are expected to migrate less frequently; however, comparisons remain scarce. We aimed to compare the distal migration rate between patients who received either straight or double-pigtail stents in the biliary drainage of ICBDS. Consecutive patients with ICBDS who received plastic biliary stents at the Venizeleio General Hospital between 2009 and 2019 were retrospectively reviewed. Distal migration was confirmed on follow-up endoscopy when the stent was no longer present at the papillary orifice nor fluoroscopically visible in the bile duct. Among 4524 ERCPs, a total of 618 biliary plastic stent placement procedures (410 patients) were performed for ICBDS: 289 (46.8%) with a straight stent (Group A) and 329 (53.2%) with a double-pigtail stent (Group B). No significant differences were observed between the two groups concerning age, gender, bile duct diameter, placement of single vs multiple biliary stents, as well as use of endoscopic sphincterotomy and balloon sphincteroplasty. The median time period of repeated endoscopy was 7 months (IQR 4-12 months). The rate of distal stent migration was 17.3% (50/289) in group A and 27.4% (90/329) in group B (p=0.003). By Kaplan-Meier analysis (Figure), freedom from distal stent migration was 91.6% and 82.7% at 6 months, 78.6% and 72.3% at 12 months, and 73% and 55% at 18 months, for groups A and B respectively (P=0.004, log-rank). Contrary to common perception, pigtail stents are more likely to migrate distally compared with straight stents in patients with ICBDS.

Clinical outcomes after multiple self-expandable metallic stent placement using stent-in-stent technique for malignant gastric outlet obstruction.

Self-expandable metallic stent (SEMS) placement is widely used for relieving symptoms in malignant gastric outlet obstruction (MGOO). This study aimed to evaluate the efficacy and safety of multiple gastroduodenal stent placement using the stent-in-stent technique and to identify factors predictive of stent patency.We retrospectively analyzed data from 170 patients with GOO receiving SEMS using the stent-in-stent technique between July 2006 and July 2018. Of these, 90 had been treated with SEMS placement for MGOO. Technical and clinical success rates were evaluated. Clinical outcomes and predictors of stent patency were also analyzed.Second SEMS placement was used in 34.4% of cases and 9.7% were treated with third SEMS placement because of prior stent dysfunction. Median stent patency time was 15.7 weeks for the first SEMS, 10.4 weeks for the second, and 11.3 weeks for the third. The technical and clinical success rates were 100% and 97.8% for the first SEMS, 100% and 90.3% for the second, respectively, and both 100% for the third. Multivariable analysis showed that use of covered SEMS and chemotherapy after first and second SEMS placement was significant predictors of stent patency. Serious complications such as bleeding or perforation did not occur in any patient.Second and third gastroduodenal SEMS placement using the stent-in-stent technique is safe and effective for management of first stent dysfunction in MGOO. Stent patency is significantly associated with the use of covered SEMS and chemotherapy after SEMS placement.

Fully covered self-expanding metal stents for benign biliary stricture after orthotopic liver transplant: 5-year outcomes

Minimally invasive treatments of anastomotic benign biliary stricture (BBS) after orthotopic liver transplantation (OLT) include endoscopic placement of multiple plastic stents or fully covered self-expandable metal stents (FCSEMSs). No multiyear efficacy data are available on FCSEMS treatment after OLT. We prospectively studied long-term efficacy and safety of FCSEMS treatment in adults aged≥18 years with past OLT, cholangiographically confirmed BBS, and an indication for ERCP with stent placement. Stent removal was planned after 4 to 6 months, with subsequent follow-up until 5 years or stricture recurrence. Long-term outcomes were freedom from stricture recurrence, freedom from recurrent stent placement, and stent-related serious adverse events (SAEs). In 41 patients, long-term follow-up began after FCSEMS removal (n= 33) or observation of complete distal migration (CDM) (n= 8). On an intention-to-treat basis, the 5-year probability of remaining stent-free after FCSEMS removal or observation of CDM was 48.9% (95% confidence interval [CI], 33.2%-64.7%) among all patients and 60.9% (95% CI, 43.6%-78.2%) among 31 patients with over 4 months of FCSEMS indwell time. In 28 patients with stricture resolution at FCSEMS removal or observed CDM (median, 5.0 months indwell time), the 5-year probability of no stricture recurrence was 72.6% (95% CI, 55.3%-90%). Sixteen patients (39%) had at least 1 related SAE, most commonly cholangitis (n= 10). By 5 years after temporary FCSEMS treatment of post-OLT BBS, approximately half of all patients remained stent-free on an intention-to-treat basis. Stent-related SAEs (especially cholangitis) were common. FCSEMS placement is a viable long-term treatment option for patients with post-OLT BBS. (Clinical trial registration number: NCT01014390.).

Novel side-by-side metal stent placement for recurrent hepatic hilar obstruction after placement of multiple metal stents.

Novel side-by-side metal stent placement for recurrent hepatic hilar obstruction after placement of multiple metal stents.

Biodegradable versus multiple plastic stent implantation in benign biliary strictures: A systematic review and meta-analysis

PurposeBenign biliary strictures arise mostly from iatrogenic injuries during surgical procedures and various inflammatory causes. Endoscopic placement of multiple plastic stents (MPS) is often regarded as the first-line therapy, albeit not without limitations. Biodegradable biliary stents (BDBS) present an alternative therapeutic option aimed at overcoming these shortcomings.The long-term stricture resolution rates between BDBS and MPS implantation in patients with benign biliary strictures (BBS) was therefore analyzed and compared, regardless of etiology. MethodUsing predefined data fields, all articles published up to July 2018 were retrospectively selected and independently extracted by two authors and then excluded according to predefined criteria. Additional studies were identified by manually searching through article references. Any disagreements between authors on study selection were resolved by consensus. Results3 studies for BDBS (n = 133) and 6 for MPS technique (n = 441) met the inclusion criteria. The overall success rate (defined as no stricture recurrence during follow-up) for BDBS implantation was 83 % (95 % [CI], 0.76–0.89), compared to 84 % (95 % [CI], 0.78–0.89) in the MPS group. Overall stent-related complication rates were reported to be slightly inferior in the BDBS group when compared to MPS, except for cholangitis (24.1 % vs. 6.1 %, respectively) and haemobilia (3% vs <1%, respectively). On average, BDBS required less interventions than MPS use (1 vs. 3, respectively). ConclusionsThe insertion of BDBS in the treatment of benign biliary strictures does not seem to be inferior to multiple plastic stents in resolving and maintaining long-term biliary duct patency, albeit exhibiting higher rates of post-procedural cholangitis.

Massive pneumopritoneum with no evidence of hollow viscus perforation, a possible hepatobiliary source; a case report

Presenter: kiarash Mashayekhi MD,MS | San Joaquin General Hospital Background: Pneumoperitoneum is most frequently caused by hollow viscous perforation, which in most cases requires an exploratory laparotomy. In the event where no perforation can be identified, one must consider other rare causes of pneumoperitoneum. Methods: We report a case of a woman who presented to the emergency department with severe abdominal pain and nausea. Results: On initial exam the patient had peritonitis, and the CT of her abdomen & pelvis showed a substantial pneumoperitoneum, with a dilated cecum and ascending colon, and gallstones within a distended gallbladder. Initial exploratory laparotomy showed no hollow viscus perforation, an unroofed left liver lobe abscess, and a distended gallbladder. Further imaging after the initial operation showed significant choledocholithiasis, although her hepatic function tests remained normal. Subsequently the patient underwent ERCP, sphincterotomy, multiple stone extraction and stent placement. Two further exploratory laparotomies were performed for cholecystectomy and drainage of liver abscess, again with no identifiable hollow viscus perforation. Cultures drawn from the peritoneal fluid and abscess grew gas-forming organisms, prominently Klebsiella Pneumoniae. Over the next few weeks the patient decompensated and developed septic shock, and multi organ failure in spite of maximal therapy; she ultimately died from septic shock due to overwhelming hepatic and intraperitoneal abscesses. Conclusion: This case highlights a very uncommon etiology for pneumoperitoneum in the absence of hollow viscus perforation, from the hepatobiliary tract, associated with ascending cholangitis from an invasive form of Klebsiella Pneumoniae liver abscess syndrome.

P75 CRITICAL APPRAISAL OF THE IMPACT OF OESOPHAGEAL STENTS IN THE MANAGEMENT OF OESOPHAGEAL ANASTOMOTIC LEAKS AND BENIGN OESOPHAGEAL PERFORATIONS: AN UPDATED SYSTEMATIC REVIEW

Abstract Aims This updated systematic review aimed to assess the safety and effectiveness of oesophageal stents in these two scenarios. Background Endoscopic placement of oesophageal stents may be used in benign oesophageal perforation and oesophageal anastomotic leakage to control sepsis and reduce mortality and morbidity by avoiding thoracotomy. Methods A systematic literature search of all published studies reporting use of metallic and plastic stents in the management of postoperative anastomotic leaks, spontaneous and iatrogenic oesophageal perforations were identified. Primary outcomes were technical (deploying ≥1 stent to occlude site of leakage with no evidence of leakage of contrast within 24-48 hours) and clinical success (complete healing of perforation or leakage by placement of single or multiple stents irrespective of whether the stent was left in situ or was removed). Secondary outcomes were stent migration, perforation and erosion and mortality rates. Subgroup analysis were performed for plastic versus metallic stents and anastomotic leaks versus perforations separately. Results A total of 66 studies (n=1752 patients) were included. Technical and clinical success rates were 96% and 87%, respectively. Plastic stents had significantly higher migration rates (24% vs 16%, p=0.001) and repositioning (11% vs 3%, p&lt;0.001) and lower technical success (91% vs 95%, p=0.032) than metallic stents. In patients with anastomotic leaks, plastic stents were associated with higher stent migration (26% vs 15%, p=0.034), perforation (2% vs 0%, p=0.013), repositioning (10% vs 0%, p&lt;0.001) and lower technical success (95% vs 100%, p=0.002). In patients with perforations only, plastic stents were associated with significantly lower technical success (85% vs 99%, p&lt;0.001). Conclusions Covered metallic oesophageal stents appear to be more effective than plastic stents in the management of oesophageal perforation and anastomotic leakage. However, quality of evidence of generally poor and high-quality randomised trial is needed to further evaluate best management option for oesophageal perforation and anastomotic leakage.

Critical Appraisal of the Impact of Oesophageal Stents in the Management of Oesophageal Anastomotic Leaks and Benign Oesophageal Perforations: An Updated Systematic Review.

Endoscopic placement of oesophageal stents may be used in benign oesophageal perforation and oesophageal anastomotic leakage to control sepsis and reduce mortality and morbidity by avoiding thoracotomy. This updated systematic review aimed to assess the safety and effectiveness of oesophageal stents in these two scenarios. A systematic literature search of all published studies reporting use of metallic and plastic stents in the management of post-operative anastomotic leaks, spontaneous and iatrogenic oesophageal perforations were identified. Primary outcomes were technical (deploying ≥ 1 stent to occlude site of leakage with no evidence of leakage of contrast within 24-48h) and clinical success (complete healing of perforation or leakage by placement of single or multiple stents irrespective of whether the stent was left in situ or was removed). Secondary outcomes were stent migration, perforation and erosion, and mortality rates. Subgroup analysis was performed for plastic versus metallic stents and anastomotic leaks versus perforations separately. A total of 66 studies (n = 1752 patients) were included. Technical and clinical success rates were 96% and 87%, respectively. Plastic stents had significantly higher migration rates (24% vs 16%, p = 0.001) and repositioning (11% vs 3%, p < 0.001) and lower technical success (91% vs 95%, p = 0.032) than metallic stents. In patients with anastomotic leaks, plastic stents were associated with higher stent migration (26% vs 15%, p = 0.034), perforation (2% vs 0%, p = 0.013), repositioning (10% vs 0%, p < 0.001), and lower technical success (95% vs 100%, p = p = 0.002). In patients with perforations only, plastic stents were associated with significantly lower technical success (85% vs 99%, p < 0.001). Covered metallic oesophageal stents appear to be more effective than plastic stents in the management of oesophageal perforation and anastomotic leakage. However, quality of evidence of generally poor and high-quality randomised trial is needed to further evaluate best management option for oesophageal perforation and anastomotic leakage.

EUS-guided biliary drainage for the management of benign biliary strictures in patients with altered anatomy: A single-center experience.

Background and Objectives:The management of benign biliary stricture in patients with altered anatomy secondary to surgery is challenging. Percutaneous transhepatic biliary drainage (BD) represents the standard therapy for benign biliary stricture, but it is associated with nontrivial morbidity rates. Despite the increasing application of guided BD (EUS-BD) for the management of malignant obstruction, its role in patients with benign biliary stricture is limited. This retrospective study aimed to evaluate the feasibility, safety, and clinical effectiveness of EUS-BD with multiple transanastomotic plastic stent treatment in patients with benign biliary stricture.Materials and Methods:This study included consecutive patients who underwent EUS-BD for benign biliary stenosis at our center. EUS-BD with fully covered self-expandable metal stent placement was performed first. When feasible, the stricture was treated by balloon dilation with the placement of a transanastomotic double-pigtail plastic stent. Scheduled procedures were repeated to remove the metal stent and replace the plastic stent to treat the stenosis. Technical success and adverse events (AEs) were assessed.Results:Twelve patients underwent EUS-BD for benign biliary strictures. Procedural and clinical successes were achieved in all patients (100%). Multistenting treatment was performed in 10/12 patients (77%). The median number of stents inserted, maximum number of stents placed, and median time of retreatment were 2.4 (range: 1–4), 4, and 3.4 (range: 1–7), respectively. In total, 4/12 patients (33.3%) developed AEs that required endoscopic interventions (Clavien-Dindo Grade III).Conclusions:EUS-BD with the placement of multiple trans-stenosis plastic stents is a safe, feasible, and well-tolerated alternative for the management of benign biliary stricture in patients with surgery-altered anatomy. Long-term follow-up is necessary to support our results.

Endotherapy of postcholecystectomy biliary strictures with multiple plastic stents: long-term results in a large cohort of patients

Endoscopic therapy of benign biliary strictures with multiple plastic stent (MPS) placement has shown satisfactory results. However, the literature describes various benign biliary stricture etiologies. The aim of this study was to evaluate long-term MPS results in patients with postcholecystectomy biliary strictures (PCBSs). PCBS patients without complete bile duct transection were included. ERCP consisted of placing an increasing plastic stent number over time, exchanged at regular intervals (3-4 months), until complete morphologic stricture disappearance. After stent removal, patient follow-up comprised liver function tests and clinical assessment. One hundred fifty-four patients (43.5% men; mean age, 53 years) were enrolled; in 43% of the cases, PCBSs were involved or were close to the main hepatic confluence. PCBS resolution rate was 96.7% (n= 149). A mean maximum number of 4.3 ± 1.6 stents were placed side-by-side; a mean of 4.2 ± 1.5 ERCPs per patient was needed to obtain PCBS resolution during a mean treatment period of 11.8 ± 6.4 months. Unscheduled stent exchange because of cholangitis, jaundice, or pain occurred in 7.4% of cases. Procedure-related mortality was absent. Follow-up data were available in 85.2% of cases. After a mean follow-up of 11.1 ± 4.9 years, stricture recurrence rate was 9.4% (n= 12). Subsequent to retreatment, 83.3% of patients (n= 10) were asymptomatic after a mean time of 9 years, whereas 2 patients underwent hepaticojejunostomy because of failed retreatment. Statistical analysis revealed no risk factors for PCBS recurrence after MPS. Endoscopic therapy of PCBSs with MPSs is safe and effective at long-term follow-up. PCBSs involving or close to the main hepatic confluence were successfully treated with MPSs. PCBS recurrence rate is low and can be successful endoscopically retreated without precluding possible surgical treatment.

Sa1072 CLINICAL OUTCOMES IN PATIENTS UNDERGOING MULTIPLE SELF-EXPANDABLE METALLIC STENT PLACEMENT BY STENT IN STENT TECHNIQUE FOR MALIGNANT GASTRIC OUTLET OBSTRUCTION

Self-expandable metallic stent (SEMS) placement is widely used for relieving the obstructive symptoms of malignant gastric outlet obstruction (MGOO). The aims were to evaluate the efficacy and safety of multiple gastroduodenal stent placement by stent in stent technique and identify predictive factors about stent patency.

Clinical outcomes in patients undergoing multiple self-expandable metallic stent placement by stent in stent technique for malignant gastric outlet obstruction.

88 Background: Self-expandable metallic stent (SEMS) placement is widely used for relieving the obstructive symptoms of malignant gastric outlet obstruction (MGOO). The aims were to evaluate the efficacy and safety of multiple gastroduodenal stent placement by stent in stent technique and identify predictive factors about stent patency. Methods: We retrospectively analyzed data from 170 patients with GOO receiving SEMS by stent in stent technique from July 2006 to July 2018. Among them, 90 patients had been treated with gastroduodenal SEMS placement for MGOO. Technical and clinical success rates were evaluated. And, clinical outcomes with predictors of stent patency were also analyzed. Results: Among the subjects, 34.4% were treated with secondary SEMS placement, and 9.7% were treated with third SEMS placement because of the previous stent dysfunction. The median stent patency time was 15.7 weeks (range 0-89) in the first SEMS, 10.4 weeks (range 0-44) in the second SEMS, and 11.3 weeks (range 1-29) in the third SEMS. The technical and clinical success rate were 100% and 97.8% in the first SEMS, 100% and 90.3% in the second SEMS, 100% and 100% in the third SEMS. In multivariable analysis, the first SEMS placement of covered type including Comvi stent was correlated with prolonged stent patency (OR 4.549, P = 0.001). And both chemotherapy after the first SEMS placement (OR 8.248, P = 0.006) and chemotherapy after the second SEMS placement (OR 7.467, P = 0.003) were correlated with prolonged stent patency. Serious complications such as gastrointestinal hemorrhage or perforation did not occur in any patient. Conclusions: Secondary and third gastroduodenal SEMS placement by stent in stent technique is a safe and effective treatment for the first stent dysfunction in MGOO. The stent placement of covered type and chemotherapy after stent placement is the predictor of stent patency. Keywords: Malignant gastric outlet obstruction, Self-expandable metallic stent, Stent in stent technique, Stent patency, Predictive factor

Metallic vs plastic stents to treat biliary stricture after liver transplantation: a systematic review and meta-analysis based on randomized trials.

Background and study aims The first-line approach to anastomotic biliary stricture after orthotopic liver transplantation (OLTX) involves endoscopic retrograde cholangiopancreatography (ERCP). The most widely used technique is placement of multiple plastic stents, but discussions are ongoing on the benefits of fully-covered self-expandable metallic stents (FCEMS) in this situation. This study aimed to compare results from use of plastic and metal stents to treat biliary stricture after transplantation. Patients and methods Searches were performed in the Medline, EMBASE, SciELO/LILACS, and Cochrane databases, and only randomized studies comparing the two techniques were included in the meta-analysis. Results Our study included four randomized clinical trials totaling 205 patients. No difference was observed between the stricture resolution rate (RD: 0.01; 95 %CI [−0.08 – 0.10]), stricture recurrence (RD: 0.13; 95 %CI [−0.03 – 0.28]), and adverse events (RD: −0.10; 95 %CI [−0.65 – 0.44]) between the plastic and metallic stent groups. The metallic stent group demonstrated benefits in relation to the number of ERCPs performed (MD: −1.86; 95 %CI [−3.12 to −0.6]), duration of treatment (MD: −105.07; 95 %CI [−202.38 to −7.76 days]), number of stents used (MD: −10.633; 95 %CI [−20.82 to −0.44]), and cost (average $ 8,288.50 versus $ 18,580.00, P < 0.001). Conclusions Rates of resolution and recurrence of stricture are similar, whereas the number of ERCPs performed, number of stents used, duration of treatment, and costs were lower in patients treated with FCEMS, which shows that this device is a valid option for initial treatment of post-OLTX biliary stricture.

Single brand, fully-covered, self-expandable metal stent for the treatment of benign biliary disease: when should stents be removed?

The two most relevant endoscopic treatable benign biliary diseases (BBD) are benign biliary strictures (BBSs) and biliary leaks (BLs), often associated with high morbidity. The most common endoscopic treatment for biliary strictures involves placement of multiple plastic stents (PSs), with or without balloon dilation, followed by planned exchange of the stents. Thus, there continues to be high interest in pursuing alternative endoscopic approaches that may achieve better results with fewer interventions. In this setting, the use of a fully-covered, self-expandable metal stent (FCSEMS) is an attractive alternative to single or multiple PSs for the treatment of BBDs. A single metal stent can remain in place for a longer period of time before removal; however, the maximum time the stent can be remain in place is still not well defined. The aim of this review is to determine the removal time of the TaeWoong® FCSEMS, placed for BBD. According to our data analysis, considering the absence of loss of the covering of the FCSEMS and of any adverse events during and after stent removal, leaving the TaeWoong medical FCSEMS in situ for an 8 months' period seems to be acceptable for benign biliary diseases. Further studies need to evaluate their removability at 1 year.

Sa1308 ENDOSCOPIC TREATMENT OF SYMPTOMATIC COMMON BILE DUCT STONES IN THE ELDERLY

Regardless of age, in Japan it is recommended that the complete removal of stones be achieved for the management of common bile duct (CBD) stones. However, in many elderly patients stones cannot be safely removed at the initial procedure because of their age and the time required to deal with many and/or large stones. In those patients endoscopic biliary stenting (EBS) is recommended as an alternative. To examine the outcome of endoscopic treatment for elderly patients with symptomatic CBD stones. From January 2016 to May 2017, we performed endoscopic retrograde cholangiopancreatography for 59 elderly patients with cholangitis due to CBD stones. Two groups were evaluated: complete clearance of CBD stones (stone clearance group) and a stenting group where drainage with a 7 Fr. double-pigtail side hole plastic stent was performed. Because of advanced age, there was no plan for regular stent changing. We compared patient profiles, procedure time, adverse events, recurrence rates of cholangitis and the time until recurrence between the two groups. The stone clearance group had 45 patients (26 men) vs. 14 in the stenting group (2 men) (P <0.001). Stenting group patients were significantly older (median age 88, range 78-96) than the stone clearance group (median age 75, range 29-96), P<0.001. The median procedure time was less with stenting than stone removal: 14 min (range 9-26) vs. 27 min (range 6-53), P <0.001. No adverse events occurred in either group. Recurrence of cholangitis was lowest in the stone clearance group [18% (8/45) vs. the stenting group, 43% (6/14), P=0.054]. However, the median time to recurrence of cholangitis was similar between those undergoing stone clearance and stenting [13.8 months (range 1-31) vs. 11 months (range 2-29), P=0.69] (Fig. 1). Although biliary stenting is an effective alternative for acute management of symptomatic choledocholithiasis in ill elderly patients, almost half suffered recurrence of cholangitis. Long term placement of a single stent is not an optimal solution. Whether stone removal after cholangitis subsides or placement of multiple stents would reduce recurrent cholangitis remains to be studied.

Same-session placement of multiple lumen-apposing metal stentsto provide effective drainage of extensive walled-off pancreatic necrosis.

Same-session placement of multiple lumen-apposing metal stentsto provide effective drainage of extensive walled-off pancreatic necrosis.

Hemodynamic Changes Caused by Multiple Stenting in Vertebral Artery Fusiform Aneurysms: A Patient-Specific Computational Fluid Dynamics Study.

The multiple stent placement technique has largely improved the long-term outcomes of intracranial fusiform aneurysms, but the hemodynamic mechanisms remain unclear. In this study, we analyzed the hemodynamic changes caused by different stent-placement strategies in patient-specific models using the computational fluid dynamics technique, aiming to provide evidence for clinical decision-making. Ten vertebral artery fusiform aneurysms were included, and their patient-specific computational fluid dynamics models were reconstructed. A fast virtual stent placement technique was used to simulate sequential multiple stent placements (from a single stent to triple stents) in the vertebral artery fusiform aneurysm models. Hemodynamic parameters, including wall shear stress, pressure, oscillatory shear index, relative residence time, and flow pattern, were calculated and compared among groups with different numbers of stents. Virtual stents were deployed in all 10 cases successfully, consistent with the real stent configuration. Wall shear stress decreased progressively by 7.2%, 20.6%, and 25.8% as the number of stents increased. Meanwhile, relative residence time and pressure increased on average by 11.3%, 15.4%, and 45.0% and by 15.7%, 21.5%, and 28.2%. The oscillatory shear index showed no stable variation trend. Flow patterns improved by weakening the intensity of the vortices and displacing the vortex center from the aneurysmal wall. Stent placement modifies hemodynamic patterns in vertebral artery fusiform aneurysms, which might favor thrombosis formation in the aneurysmal sac. This effect is amplified with the number of stents deployed. However, a potential risk of rupture or recanalization exists and should be considered when planning to use the multiple stent placement technique in vertebral artery fusiform aneurysms.

Congested bile can predict the outcomes of endoscopic stenting for hilar biliary malignancies.

Endoscopic management of malignant hilar biliary obstruction (MHBO) remains challenging, with relatively poor jaundice control and high infectious risk. The factors that affect the outcome of endoscopic therapy are still unclear. This retrospective cohort study aimed to investigate predictive factors for the outcomes of biliary stenting in patients with MHBO. Between June 2015 and June 2016, consecutive patients with MHBO who received primary endoscopic stenting and completed follow-up at our institution were identified and evaluated. All patients received full aspiration of congested bile followed by plastic or metal stent(s) placement. Clinical success was achieved in patients whose total serum bilirubin decreased by over two-thirds in a month. A total of 64 patients were included. Among them, 28 received a single stent placement and 36 received multiple stent placements. Altogether 53 (82.8%) patients attained clinical success and 48 (75.0%) underwent re-interventions within 6 months. Multivariate analyses showed that only a total bile volume of ≥30 mL aspirated from the intrahepatic ducts predicted clinical success (OR 6.83, 95% CI 1.2-38.4, P = 0.029), absence of early post-endoscopic retrograde cholangiopancreatography cholangitis (OR 0.03, 95% CI 0.004-0.36, P = 0.001), and lack of re-intervention within 6 months (HR 0.10, 95% CI 0.05-0.22, P < 0.001) after initial endoscopic stenting. The volume of congested bile may effectively predict treatment outcomes of endoscopic stenting for MHBO and guide the therapeutic strategy.