Recurrent Obstruction Research Articles

Adverse events of self-expandable metal stent placement for malignant distal biliary obstruction: a large multicenter study

Background and aimEndoscopic placement of self-expandable metal stents (SEMSs) for malignant distal biliary obstruction (MDBO) may be accompanied by several types of adverse events. The present study analyzed the adverse events occurring after SEMS placement for MDBO. MethodsThe present study retrospectively investigated the incidence and types of adverse events in patients who underwent SEMS placement for MDBO between April 2018 and March 2021 at 26 hospitals. Risk factors for acute pancreatitis, cholecystitis, and recurrent biliary obstruction (RBO) were evaluated by univariate and multivariate analyses. ResultsOf the 1425 patients implanted with SEMS for MDBO, 228 (16.0%) and 393 (27.6%) experienced early adverse events and RBO, respectively. Pancreatic duct without tumor involvement (p = 0.023), intact papilla (p = 0.025), and SEMS placement across the papilla (p = 0.037) were independent risk factors for acute pancreatitis. Tumor involvement in the orifice of the cystic duct (OCD) was an independent risk factor for cholecystitis (p < 0.001). Fully and partially covered SEMSs were independent risk factors for food impaction and/or sludge. Fully covered SEMS was an independent risk factor for stent migration. Uncovered SEMS and laser-cut SEMS were independent risk factors for tumor ingrowth. ConclusionsPancreatic duct without tumor involvement, intact papilla, and SEMS placement across the papilla were independent risk factors for acute pancreatitis, and tumor involvement to the OCD was an independent risk factor for cholecystitis. The risk factors for food impaction and/or sludge, stent migration, and tumor ingrowth differed among types of SEMS.

Second Covered and Uncovered Self-Expandable Metal Stents for Recurrent Gastric Outlet Obstruction: A Retrospective Comparative Study.

Background: Endoscopic self-expandable metal stent (SEMS) placement is a current mainstay for malignant gastric outlet obstruction (GOO), but symptomatic recurrence due to initial SEMS dysfunction commonly occurs. We aimed to compare the safety and effectiveness of second SEMS for recurrent GOO (RGOO). Methods: Between April 2006 and December 2022, a total of 95 cases with malignant RGOO undergoing second endoscopic SEMS placement were enrolled. Technical and clinical success rates, RGOO, time to RGOO (TRGOO), stent patency rate, adverse events (AE), and overall survival (OS) were retrospectively compared between covered and uncovered SEMS (cSEMS/uSEMS) groups. Risk factors for TRGOO were also explored. Results: Baseline characteristics were well balanced between cSEMS (n = 48) and uSEMS (n = 47) groups, except for the causes of the initial SEMS dysfunction. High technical and clinical success rates with a similar incidence of AE (15% vs. 17%, p = 0.78) and OS (median of 101 vs. 102 days, p = 0.68) were achieved in both groups. There were no statistical differences in cumulative incidence of RGOO (19% vs. 13%, p = 0.58), TRGOO (median, not reached in both groups, p = 0.57), and stent patency rates at 1, 2, and 3 months between the groups (60%, 47% and 26%, respectively vs. 70%, 55% and 38%, respectively). However, TRGOO tended to be longer in cSEMS in cases with RGOO due to tumor ingrowth (median, not reached vs. 111 days, p = 0.19). A Cox regression analysis demonstrated that chemotherapy after second SEMS placement was significantly associated with an improved TRGOO (the hazard ratio of 0.27 [95% confidence interval, 0.08-0.93], p = 0.03). Conclusions: Regardless of the type of SEMS, second SEMS placement was similarly safe and effective for RGOO. The type of second SEMS might be considered based on the cause of initial SEMS dysfunction.

A Japanese Prospective, Multicenter Study of Colonic Stenting for Palliation Using a High Axial Force Self-Expandable Metal Stent for Malignant Large Bowel Obstruction in 200 Patients.

Evidence of the efficacy and safety of colorectal stent placement for palliation remains insufficient. This single-arm, prospective, multicenter study with a WallFlex enteral colonic stent included 200 consecutive patients with malignant large bowl obstruction in the palliation cohort. The technical and clinical success, as well as stent patency and complications as short-term (≤7 days) and long-term (>7 days) outcomes, of high axial force self-expandable metal stent (SEMS) placement was evaluated. The technical and clinical success rates were 98.5% and 94.5%, respectively. Non-recurrent colorectal obstruction at 1 year was 63.9%, and 71.2% of the patients remained free of recurrent colorectal obstruction until death or the last follow-up. Fifty-six patients (28.0%) received chemotherapy, and five patients were administered bevacizumab after stent placement. The overall complication rate was 47%, including four (2.0%) early-onset and ten (5.0%) late-onset perforations, mostly due to stent-edge injury. Only the use of a long SEMS was a risk factor for perforation. In conclusion, endoscopic colorectal stenting using high axial force SEMS is an effective and safe procedure for palliation in patients with malignant colorectal obstruction. However, care should be taken to avoid perforation at the stent edge when using a long SEMS.

Suprapapillary placement of plastic versus metal stents for malignant biliary hilar obstructions: a multicenter, randomized trial.

The efficacy of the suprapapillary placement of inside plastic stents (iPSs) for unresectable malignant hilar biliary obstructions (MHOs) is unknown compared with that of uncovered inside metal stents (iMSs). This randomized controlled trial was designed to evaluate the outcomes of endoscopic placement of these stents for unresectable MHOs. This open-label, randomized study was conducted at 12 Japanese institutions. The enrolled patients with unresectable MHOs were allocated to iPS and iMS groups. The primary outcome was defined as the time to recurrent biliary obstruction in patients for whom the intervention was both technically and clinically successful. Among 87 enrollments, 38 patients in the iPS group and 46 patients in the iMS group were analyzed. Technical success rates were 100% (38 of 38) and 96.6% (44 of 46), respectively (P= 1.00). After transferring 1 unsuccessful iMS-group patient to the iPS group (since iPSs were deployed), the clinical success rates were 90.0% (35 of 39) for the iPS group and 88.9% (40 of 45) for the iMS group from a per-protocol analysis (P= 1.00). Among the patients with clinical success, the median times to recurrent biliary obstruction were 250 (95% confidence interval, 85-415) and 361 (95% confidence interval, 107-615) days (log-rank test, P= .34). No differences were detected in rates of adverse events. This Phase II randomized trial did not show any statistically significant difference in stent patency between suprapapillary plastic versus metal stents. Considering the potential advantages of plastic stents for malignant hilar obstruction, these findings suggest that suprapapillary plastic stents could be a viable alternative to metal stents for this condition.

Endoscopic reintervention after unilateral metal stent deployment for MHBO using SIS method.

Endoscopic biliary drainage is the main treatment for unresectable malignant hilar biliary obstruction (MHBO). Recurrent biliary obstruction (RBO) often occurs after unilateral metal stent deployment. Endoscopic reintervention can be complex for this problem, especially for drainage of the contralateral bile duct. The stent-in-stent (SIS) method is a possible solution to this problem. Our objective was to evaluate the safety and feasibility of the SIS method for endoscopic reintervention in patients with RBO due to MHBO after unilateral metal stent deployment. Eleven patients with MHBO received endoscopic reintervention using the SIS method to manage RBO after unilateral metal stent deployment. Clinical data, including technical and clinical success, procedure time, adverse events and complications, stent patency, RBO of the revisionary stent, and survival time were recorded. Nine patients (82%) achieved technical success, and all 9 of them also achieved clinical success. The 2 unsuccessful cases received percutaneous transhepatic cholangial drainage. The median procedure time was 73 minutes. The 3 adverse events were post-endoscopic retrograde cholangiopancreatography pancreatitis, cholangitis, and liver abscess. 6 patients (67%) experienced RBO of the revisionary stent, the median time to RBO of the revisionary stent was 95.5 days, the median survival time after reintervention was 111 days, and the median overall survival time was 305.5 days. Endoscopic reintervention after previous unilateral metal stent deployment using the SIS method appears to be safe and technically feasible for MHBO patients who experience RBO.

A clinical nomogram for predicting small bowel obstruction after extubation after radical resection of esophageal cancer and jejunostomy

BackgroundSmall bowel obstruction after extubation is among the most serious complications of radical esophageal cancer and jejunostomy resection. This study aimed to explore the risk factors and treatment methods for small bowel obstruction after extubation and construct a predictive model to guide its clinical management. MethodsClinical data for 514 patients who underwent esophagectomy with jejunostomy for esophageal cancer were collected. A nomogram was constructed using the independent risk factors for small bowel obstruction after extubation determined on multivariable logistic regression analysis, and a subgroup analysis was performed of the treatment methods for the 61 patients with small bowel obstruction after extubation. ResultsThe nomogram incorporated the independent risk factors for small bowel obstruction after extubation (gastrointestinal function recovery [P < .001], postoperative albumin reduction ratio [P = .009], and serious postoperative complications [P < .001]) in the multivariable logistic regression analysis. The final model had an area under the curve of 0.829 (95% confidence interval, 0.775–0.883). The calibration plots demonstrated high concordance between the predicted and actual probabilities. The model demonstrated excellent discriminatory power for internal and time validation, with adjusted C-statistics of 0.821 and 0.810 (95% confidence interval, 0.686–0.933), respectively. In the subgroup analysis, an abnormal anion gap (P = .016) and low serum albumin level (P = .005) were associated with recurrent small bowel obstruction. The model’s area under the curve was 0.815 (95% confidence interval, 0.683–0.948). The probability of recurrence among patients with small bowel obstruction after extubation was 78.3% when the 2 risk factors were present. ConclusionThe clinical nomogram based on small bowel obstruction after extubation predictors recommends aggressive surgical intervention for patients with small bowel obstruction after extubation and an abnormal anion gap and low serum albumin level at admission.

Late Outcomes of Konno-Rastan and Modified Konno for Left Ventricular Outflow Tract Obstruction

BackgroundWhile early outcomes of the Konno-Rastan and modified Konno procedures are known, long-term outcomes remain undetermined. Our objective was to examine long-term clinical and echocardiographic outcomes. MethodsRetrospective review was performed of patients undergoing Konno-Rastan and modified Konno for complex left ventricular outflow tract (LVOT) obstruction from January 1980 to January 2021. The Ross-Konno procedure was excluded due to its often limited ventriculotomy. ResultsA total of 92 patients were identified: 73 Konno-Rastan and 19 modified Konno. The modified Konno group was significantly younger (median [interquartile range, IQR]: 6, [2-12] years vs 16 [9-32] years, P = .001). LVOT obstruction was multilevel (39 of 92 [42.4%]), tunnel subaortic (35 of 92 [38.0%]), or aortic valve stenosis/annular hypoplasia (18 of 92 [19.6%]). Shone syndrome was present in 20 of 92 (21.7%) patients. Operative mortality was 7 of 92 (7.6%); 4 of 86 (4.7%) in elective vs 3 of 6 (50.0%) in urgent cases (P = .005). Median follow-up was 12 (IQR, 5-22) years. Aortic valve/LVOT mean gradient was 13 (IQR, 10-18) mm Hg at 1 year but gradually increased to 25 (IQR, 13-46) mm Hg at 10 years. Ejection fraction remained normal. Freedom from reoperation at 5 and 10 years was 77.2% and 58.4% among Konno-Rastan and 57.7% and 41.7% among modified Konno patients (P = .28), respectively. Overall survival at 5, 10, and 15 years was 82.9%, 76.3%, and 65.5%. Risk factors for mortality included older age, New York Heart Association class III/IV, longer cardiopulmonary bypass time, and multilevel LVOT obstruction. ConclusionsWhile LVOT obstruction is alleviated early, recurrent LVOT obstruction occurs over time after Konno-Rastan and modified Konno procedures. Additionally, despite preserved left ventricular systolic function, late overall survival is poor in this young population.

Impact of sarcopenia on biliary drainage during neoadjuvant therapy for pancreatic cancer.

Since the usefulness of neoadjuvant chemo(radiation) therapy (NAT) for pancreatic cancer has been demonstrated, recurrent biliary obstruction (RBO) in patients with pancreatic cancer with a fully covered self-expandable metal stent (FCSEMS) during NAT is expected to increase. This study investigated the impact of sarcopenia on RBO in this setting. Patients were divided into normal and low skeletal muscle index (SMI) groups and retrospectively analyzed. Patient characteristics, overall survival, time to RBO (TRBO), stent-related adverse events, and postoperative complications were compared between the two groups. A Cox proportional hazard model was used to identify the risk factors for short TRBO. A few significant differences were observed in patient characteristics, overall survival, stent-related adverse events, and postoperative complications between 38 patients in the normal SMI group and 17 in the low SMI group. The median TRBO was not reached in the normal SMI group and was 112 days in the low SMI group (p=0.004). In multivariate analysis, low SMI was the only risk factor for short TRBO, with a hazard ratio of 5.707 (95% confidence interval, 1.148-28.381; p=0.033). Sarcopenia was identified as an independent risk factor for RBO in patients with pancreatic cancer with FCSEMS during NAT.

Preliminary feasibility study of a new partially covered self-expandable metal stent with an anchoring flange for EUS-guided hepaticogastrostomy (with videos)

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) has a risk of serious procedural adverse events (AEs), but few dedicated devices for EUS-HGS are available. We evaluated the feasibility of a new partially covered self-expandable metal stent (PCSEMS) with an anchoring flange for EUS-HGS. The feasibility of a stent featuring a proximal radiopaque uncovered portion 1.5 cm in length and a distal anchoring flange 20 mm in diameter was evaluated in consecutive patients undergoing EUS-HGS for unresectable malignant biliary obstruction. The primary outcome was technical and clinical success with regard to the EUS-HGS, and the secondary outcomes were adverse events (AEs), recurrent biliary obstruction (RBO), re-intervention for RBO, and the technical feasibility of peroral cholangioscopy (POC) through the stent in situ. EUS-HGS was performed in 24 patients with unresectable malignant biliary obstruction. The technical and clinical success rates of EUS-HGS were 100% (24/24) and 91.7% (22/24), respectively. AEs developed after EUS-HGS in 8.3% of the patients (2/24, cholangitis). RBO developed in 29.2% of the patients (7/24), with a median cumulative time to RBO of 6.7 months. The causes of RBO were sludge formation (n = 4), hyperplasia at an uncovered portion (n = 2), and nonocclusive cholangitis (n = 1). Re-intervention for RBO had a 100% success rate (7/7), and POC through the stent in situ was technically feasible in seven out of eight patients with a stent diameter of 10 mm. EUS-HGS with a new PCSEMS can alleviate malignant biliary obstruction after failed ERCP. The novel stent evaluated in this study may prevent stent-related AEs including stent migration and allow advanced endoscopic interventions through the HGS route.

Endoscopic ultrasound-guided hepaticogastrostomy versus choledochoduodenostomy for malignant biliary obstruction: A meta-analysis.

Endoscopic ultrasound (EUS)-guided biliary drainage encompasses techniques such as EUS-guided hepaticogastrostomy (EUS-HGS) and EUS-guided choledochoduodenostomy (EUS-CDS). This meta-analysis compared the efficacy of EUS-CDS with that of EUS-HGS for the treatment of biliary obstruction. A systematic meta-analysis of all relevant articles listed was performed by searching the Cochrane Library, PubMed, and Google Scholar databases. We used random effects or fixed effects models to compare success rates, adverse events, procedure times, and time to recurrent biliary obstruction after EUS-CDS and EUS-HGS. This meta-analysis included 18 eligible studies. There was no significant difference between EUS-CDS and EUS-HGS with respect to technical success rate (odds ratio [OR] 1.04; 95% confidence interval [CI] 0.62-1.73) and clinical success rate (OR 0.66; 95% CI 0.43-1.04), or with respect to total procedure-related adverse events (OR 1.39; 95% CI 1.00-1.93). Subgroup analysis of adverse events revealed that the rate of recurrent biliary obstruction (RBO) was significantly higher for EUS-HGS (OR 2.95; 95% CI 1.54-5.64). There was no significant difference between the two methods with respect to time to recurrent biliary obstruction (mean difference -11.93 days; 95% CI -47.77-23.91). However, the procedure time was longer for EUS-HGS (mean difference, 3.21 min; 95% CI 1.24-5.19). EUS-CDS and EUS-HGS are comparable in terms of technical success, clinical success, and rate of adverse events; however, EUS-CDS is superior with respect to procedure time and preventing RBO.

Comparable Efficacy of Laser-Cut and Braided Self Expanding Metallic Biliary Stent: A Systematic Review and Meta-Analysis.

In patients with unresectable malignant biliary obstruction (MBO), endoscopic biliary drainage is the treatment of choice. Self-expanding metallic stents (SEMS) are mainly used for this purpose, and data is limited on the comparative outcomes of laser-cut versus braided SEMS. Herein, we performed the first systematic review and meta-analysis to study the effectiveness and safety of braided and laser-cut SEMS in MBO. Multiple databases, including Medline, Scopus, and Embase, were searched (in May 2022) using specific terms for studies evaluating the outcomes of braided and laser-cut SEMS in MBO. Outcomes of interest were technical and clinical success, recurrent biliary obstruction, and adverse events. Standard meta-analysis methods were employed using the random-effects model. I2% heterogeneity was used to assess the heterogeneity. Seven studies were included in the final analysis. (Laser-cut: 271 patients, 46% females, mean age 70years; and braided: 282 patients, 47% females, mean age 72years). The pooled rate of technical success and clinical success with laser-cut SEMS was 99% (95% CI [95-99; I2 = 0%]), 86% [60-96; I2 = 74%], and 98% [96-99; I2 = 0%], 89% [74-95; I2 = 78%] with braided. The pooled rate of recurrent biliary obstruction with laser-cut SEMS was 26% [14-43; I2 = 88%] and 12% [5-27; I2 = 56%) with braided. Pooled total adverse events were 11% [5-21; I2 = 77%] in laser-cut and 12% [6-24; I2 = 63%] in braided. Our meta-analysis demonstrates similar clinical outcomes with laser-cut and braided SEMS in MBO. Given the comparable performance, a cost-effectiveness analysis might help in choosing one type versus another in patients with MBO.

Comparison of metal versus plastic stent for preoperative biliary drainage in patients with pancreatic cancer undergoing neoadjuvant therapy: a meta-analysis and systematic review

BackgroundThis study was performed to compare a metal stent (MS) and plastic stent (PS) in terms of efficacy and complications during neoadjuvant therapy (NAT) and the perioperative period.MethodsWe performed an electronic search of the following databases until 1 June 2022: PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. Studies comparing an MS versus PS for PBD in patients with pancreatic cancer undergoing NAT were included.ResultsThe meta-analysis showed that use of an MS was associated with lower rates of reintervention (p < 0.00001), delay of NAT (p = 0.007), recurrent biliary obstruction (RBO) (p = 0.003), and cholangitis (p = 0.03). There were no significant differences between the two groups in terms of stent migration (p = 0.31), postoperative complications (p = 0.20), leakage (p = 0.90), and R0 resection (p = 0.50).ConclusionsUse of an MS for PBD in patients with pancreatic cancer undergoing NAT followed by surgery was associated with lower rates of reintervention, delay of NAT, RBO, and cholangitis compared with use of a PS. However, the postoperative outcomes were comparable between the MS and PS. Further studies on this topic are recommended.

A novel fully covered metal stent for unresectable malignant distal biliary obstruction: results of a multicenter prospective study.

Endoscopic self-expandable metal stent (SEMS) placement is currently the standard technique for treating unresectable malignant distal biliary obstructions (MDBO). Therefore, covered SEMS with longer stent patency and fewer migrations are required. This study aimed to assess the clinical performance of a novel, fully covered SEMS for unresectable MDBO. This was a multicenter single-arm prospective study. The primary outcome was a non-obstruction rate at 6 months. The secondary outcomes were overall survival (OS), recurrent biliary obstruction (RBO), time to RBO (TRBO), technical and clinical success, and adverse events. A total of 73 patients were enrolled in this study. The non-obstruction rate at 6 months was 61%. The median OS and TRBO were 233 and 216 days, respectively. The technical and clinical success rates were 100% and 97%, respectively. Furthermore, the rate of occurrence of RBO and adverse events was 49% and 21%, respectively. The length of bile duct stenosis (<2.2 cm) was the only significant risk factor for stent migration. The non-obstruction rate of a novel fully covered SEMS for MDBO is comparable to that reported earlier but shorter than expected. Short bile duct stenosis is a significant risk factor for stent migration.

Polyvinylpyrrolidone-coated catheters decrease choroid plexus adhesion and improve flow/pressure performance in an in vitro model of hydrocephalus.

Proximal catheter obstruction is the leading cause of ventricular shunt failure in pediatric patients. Our aim is to evaluate various types of shunt catheters to assess in vitro cellular adhesion and obstruction. Four catheter types were tested: (1) antibiotic and impregnated, (2) barium-stripe polyvinylpyrrolidone coated (PVP), (3) barium-stripe, and (4) barium-impregnated. Catheters were seeded with choroid plexus epithelial cells to test cellular adhesion and inoculated with the same cells to test flow/pressure performance under choroid plexus growth conditions. Ventricular catheters were placed into a three-dimensional printed phantom ventricular replicating system through which artificial cerebrospinal fluid (CSF) was pumped. Differential pressure sensors were used to measure catheter performance. PVP catheters had the lowest median cell attachment (10 cells) compared to antibiotic-impregnated (230 cells), barium stripe (513 cells), and barium-impregnated (146 cells) catheters after culture (p < 0.01). In addition, PVP catheters (- 0.247cm H2O) and antibiotic-impregnated (- 1.15cm H2O) catheters had significantly lower pressure in the phantom ventricular system compared to the barium stripe (0.167cm H2O) and barium-impregnated (0.618cm H2O; p < 0.01) catheters. PVP catheters showed less cellular adhesion and, together with antibiotic-impregnated catheters, required less differential pressure to maintain a consistent flow. Our findings suggest clinical relevance for using PVP ventricular catheters in patients with recurrent catheter obstruction by choroid plexus.

Scientific substantiation of approaches to physical rehabilitation of children with recurrent bronchial obstruction

Scientific substantiation of approaches to physical rehabilitation of children with recurrent bronchial obstruction

Interdigitating Technique for Repair of Aortic Arch Obstruction to Reduce Reintervention Rates

BackgroundThe incidence of reintervention for aortic arch obstruction is 5% to 14% after coarctation or hypoplastic aortic arch repair and 25% after the Norwood procedure. Institutional practice review indicated higher than reported reintervention rates. Our aim was to assess the impact of an interdigitating reconstruction technique on reintervention rates for recurrent aortic arch obstruction. MethodsChildren (<18 years) were included if they had undergone aortic arch reconstruction by sternotomy or the Norwood procedure. Three surgeons participated in the intervention with staggered rollout dates between June 2017 and January 2019, with the study ending December 2020 and review for reinterventions ending February 2022. Preintervention cohorts represented patients who underwent aortic arch reconstructions with patch augmentation, and postintervention cohorts represented patients who underwent an interdigitating reconstruction technique. Reinterventions by cardiac catheterization or operation were measured within 1 year of initial operation. Wilcoxon rank sum and χ2 tests were used to compare preintervention and postintervention cohorts. ResultsOverall, 237 patients were included for participation in this study, with 84 patients in the preintervention cohort and 153 in the postintervention cohort. Patients undergoing the Norwood procedure represented 30% (n = 25) of the retrospective cohort and 35% (n = 53) of the intervention cohort. Overall reinterventions were significantly decreased after the study intervention from 31% (n = 26/84) to 13% (n = 20/153; P < .001). Reintervention rates were decreased for each intervention cohort: aortic arch hypoplasia (24% [n = 14/59] vs 10% [n = 10/100]; P = .019) and Norwood procedure (48% [n = 12/25] vs 19% [n = 10/53]; P = .008). ConclusionsThe interdigitating reconstruction technique for obstructive aortic arch lesions was successfully implemented and is associated with a decrease in reinterventions.

EUS-guided gastroenterostomy vs. surgical gastrojejunostomy and enteral stenting for malignant gastric outlet obstruction: a meta-analysis.

Background and study aims Malignant gastric outlet obstruction (MGOO) is traditionally treated with surgical gastrojejunostomy (SGJ), which is effective but associated with high rates of morbidity, or endoscopic stenting (ES), which is less invasive but associated with significant risk of stent dysfunction and need for reintervention. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) provides a robust bypass without the invasiveness of surgery. Methods We performed a systematic review and meta-analysis comparing EUS-GE to SGJ and ES for MGOO. Electronic databases were searched from inception through February 2022. A meta-analysis was performed with results reported as odds ratios (ORs) with 95% confidence intervals (CIs) using random effects models. Primary outcomes included clinical success without recurrent GOO and adverse events (AEs). Results Sixteen studies involving 1541 patients were included. EUS-GE was associated with higher clinical success without recurrent GOO compared to ES or SGJ [OR 2.60, 95% CI1.58-4.28] and compared to ES alone [OR 5.08, 95% CI 3.42-7.55], but yielded no significant difference compared to SGJ alone [OR 1.94, 95% CI 0.97-3.88]. AE rates were significantly lower for EUS-GE compared to ES or SGJ grouped together [OR 0.34, 95% CI 0.20-0.58], or SGJ alone [OR 0.17, 95% CI 0.10-0.30] but were not significant different versus ES alone [OR 0.57, 95% CI 0.29-1.14]. Conclusions EUS-GE is the most successful approach to treating MGOO, exhibiting a lower risk of recurrent obstruction compared to ES, and fewer AEs compared to SGJ.

Utility of bilateral intraductal plastic stent for malignant hilar biliary obstruction compared with bilateral self-expandable metal stent: a propensity score–matched cohort analysis

Intraductal plastic stent (IS) placement for unresectable malignant hilar biliary obstruction (UMHBO) is an effective option for biliary drainage. However, the effectiveness of bilateral IS placement compared with bilateral self-expandable metal stent (SEMS) placement remains unclear. Overall, 301 patients with UMHBO were enrolled; 38 patients underwent bilateral IS placement (IS group) and 38 patients underwent SEMS placement (SEMS group) in the propensity score-based cohort. Both groups were compared for technical and clinical success, adverse events (AEs), recurrent biliary obstruction (RBO), time to RBO (TRBO), overall survival (OS), and endoscopic reintervention (ERI). No significant differences were observed between the groups regarding technical and clinical success, AEs and RBO occurrence rates, TRBO, or OS. The median initial endoscopic procedure time was significantly shorter in the IS group (23 vs 49 minutes, P< .01). ERI was performed on 20 and 19 patients in the IS and SEMS groups, respectively. The median ERI procedure time was significantly shorter in the IS group (22 vs 35 minutes, P= .04). Median TRBO after ERI with plastic stent placement tended to be longer in the IS group (306 vs 56 days, P= .068). A Cox multivariate analysis showed that the IS group was the significant related factor for TRBO after ERI (hazard ratio, .31; 95% confidence interval, .25-.82; P= .035). Bilateral IS placement can reduce the duration of the endoscopic procedure and provide sufficient stent patency both initially and after ERI stent placement, and the stents are removable. Bilateral IS placement is considered a good option for initial UMHBO drainage. (Clinical trial registration number: UMIN000050546.).

Fully covered self-expandable metallic stents versus plastic stents for preoperative biliary drainage in patients with pancreatic head cancer and the risk factors for post-endoscopic retrograde cholangiopancreatography pancreatitis.

Optimal stents for preoperative biliary drainage (PBD) for patients with possible resectable pancreatic cancer remain controversial, and risk factors for post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP), followed by PBD, are unknown. In this study, the efficacy and safety of fully covered self-expandable metallic stents (FCSEMSs) and plastic stents (PSs) were compared, and the risk factors for PEP, followed by PBD, were investigated for patients with pancreatic cancer. Consecutive patients with pancreatic cancer who underwent PBD between April 2005 and March 2022 were included. We retrospectively evaluated recurrent biliary obstruction, adverse events (AEs), and postoperative complications for FCSEMS and PS groups and investigated the risk factors for PEP. A total of 105 patients were included. There were 20 patients in the FCSEMS group and 85 patients in the PS group. For the FCSEMS group, the rate of recurrent biliary obstruction (0% vs. 25%, p = 0.03) was significantly lower. There was no difference in AE between the two groups. No significant differences were observed in the overall postoperative complications, but the volume of intraoperative bleeding was larger for the PS group than it was for the FCSEMS group (p < 0.001). From multivariate analysis, being female and lack of main pancreatic duct dilation were independent risk factors for pancreatitis (odds ratio, 5.68; p = 0.028; odds ratio, 4.91; p = 0.048). FCSEMSs are thought to be preferable to PSs for PBD due to their longer time to recurrent biliary obstruction. Being female and the lack of main pancreatic duct dilation were risk factors for PEP.

Extravesicular, two-layer, side-to-side ureteroneocystostomy combined with tension-relieving techniques for feline proximal ureteral obstruction: A retrospective study.

To describe the surgical technique for extravesicular, two-layer, side-to-side ureteroneocystostomy combined with tension-relieving techniques (ETSUTT) for feline proximal ureteral obstruction and report clinical outcomes. Retrospective case series. Ten privately-owned cats with ureteral obstruction near the ureteropelvic junction (UPJ). Medical records were retrospectively reviewed for cats with ureteral obstruction close to the UPJ that underwent ETSUTT (2018-2021). The ETSUTT procedure consisted of a modified extravesicular technique (two-layer, side-to-side ureteroneocystostomy) and tension-relieving techniques (renal descensus, ureterocystopexy, and nephrocystopexy). All cats survived through discharge. In all cats, postoperative blood urea nitrogen and creatinine concentrations were decreased, compared with preoperative concentrations. Perioperative complications included ureteral catheter dislodgement (3), transient pollakiuria (2), and dysuria (1), but no specific treatments were required. Urinary tract infection was observed postoperatively in three of the 10 cats. The median follow-up was 648 days (min-max: 86-1229 days). Seven of the 10 cats were alive without recurrent ureteral obstruction at the end of this retrospective study. The ETSUTT procedure was successfully performed without major complications in cats with ureteral obstruction occurring near the UPJ. Use of ETSUTT provided a fair-to-good, long-term prognosis in cats that were otherwise difficult to manage. This novel procedure, ETSUTT, was feasible, safe, and could be a viable treatment option for feline proximal ureteral obstruction, including the UPJ, especially for obstructions caused by stricture.