Short-term Stenting Research Articles

Optimizing the outcome of non-pre-stented flexible ureteroscopic lithotripsy regarding the quality of life, when to remove the stent?

ObjectivesTo investigate the safety of short-term stenting following flexible ureteroscopic lithotripsy (fURL) for patients without preoperative stents. Retaining double-J stent for 1–2 weeks after fURL is a common practice. At present, data on short-term stenting after non-pre-stented fURL is still lacking.Methods182 patients who met inclusion criteria were retrospectively divided into the 2-days group (2-day removal, 76 cases) and the 1-week group (1-week removal, 106 cases). The study endpoint was stent-associated adverse symptoms assessed by follow-up and completed validated questionnaires on postoperative days (POD) 7 and 12. A postoperative imaging review was performed 1 month after the surgery.ResultsNo statistical differences were found in the patients’ demographic and stone-related characteristics. The 2-days group showed fewer urinary tract symptoms and lower scores on the ureteral stent symptom questionnaire on POD 7: less backache during urination (p = 0.004), less hematuria (p = 0.031), less frequent urination (p = 0.004), lower urinary symptoms index (p < 0.001), lower general health index (p < 0.001), and lower performance index (p < 0.001). There were no significant differences in fever (p = 0.372), visual analogue scale score (p = 0.760), and painkiller requirements (p = 0.160) on POD 7. The average general health score and work performance score remained significantly higher in the 1-week group patients at 5 days after removal compared to the 2-days group patients at 5 days after removal. (p < 0.001, p = 0.005). Five patients in the 2-days group and 15 patients in the 1-week group returned to the emergency department for additional treatments. No patient required rehospitalization. Stone-free rates were 85.5% in the 2-days group and 80.2% in the 1-week group (p = 0.499), respectively, and none of the patients got aggravating hydronephrosis.ConclusionsCompared to the common 1-week stent removal option, short-term stenting after non-pre-stented fURL is safe, which can enhance the patient’s quality of life.

Complete intraureteral stent placement reduces stent-related symptoms: Systemic review and meta-analysis

The distal coil of a double-J ureteral stent is considered the major cause of stent-related symptoms. We noticed that some recent studies investigated whether complete intraureteral stent placement (CIU-SP) reduced these symptoms. The current systemic review and meta-analysis aimed to evaluate the safety and the effectiveness of CIU-SP, as compared to conventional stent placement (C-SP). We retrieved relevant trials published before December 2021 from three databases, including PubMED, Embase, and Web of Science. The following medical subject heading were used ((complete intraureteral stent) OR (suture stent)) AND (symptom OR pain) AND (randomized OR randomised). The above search was limited to English language publication. We identified six prospective randomized trials, all of which investigated a short-term (1-2 weeks) stent placement following uncomplicated ureteroscopic lithotripsy. The meta-analysis revealed that CIU-SP significantly reduced stent-related symptoms: CIU-SP had lower USSQ (Ureteral Stent Symptom Questionnaire) Urinary Symptom Index score (MD -5.13; 95%CI [-5.82,-4.44]; P<0.00001), lower USSQ Pain Index score (MD -4.21; 95%CI [-5.25,-3.17]; P<0.00001), and lower VAS pain scale (MD -1.93; 95%CI [-2.17,-1.69]; p<0.00001). Besides, patients with CIU-SP were less likely to have pain (RR 0.78; 95%CI [0.67,0.91]; p=0.001). There was no significant difference regarding the USSQ General Health and Work Performance. Both CIU-SP and C-SP had similarly few complications of Clavien-Dindo grade ≥2. This meta-analysis reveals that CIU-SP significantly decreases stent-related urinary symptoms and pain. Based on the current evidence, CIU-SP is ready to be applied in clinical practice, at least in those requiring short-term stent placement following uncomplicated ureteroscopic lithotripsy.

PD50-10 EVALUATING THE ENCRUSTATION FEATURES DUE TO THE SHORT-TERM URETERAL STENT PLACEMENT USING MICRO-COMPUTED TOMOGRAPHY: THE RESULTS FROM A PROSPECTIVE STUDY

You have accessJournal of UrologyCME1 May 2022PD50-10 EVALUATING THE ENCRUSTATION FEATURES DUE TO THE SHORT-TERM URETERAL STENT PLACEMENT USING MICRO-COMPUTED TOMOGRAPHY: THE RESULTS FROM A PROSPECTIVE STUDY Shinji Fukui, Takashi Yoshida, Kuniko Takemoto, and Hidefumi Kinoshita Shinji FukuiShinji Fukui More articles by this author , Takashi YoshidaTakashi Yoshida More articles by this author , Kuniko TakemotoKuniko Takemoto More articles by this author , and Hidefumi KinoshitaHidefumi Kinoshita More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002621.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: To evaluate the short-term encrustation formation and encrustation volume of the ureteral stent, focusing on the major stone components (i.e., calcium oxalate and calcium phosphate). METHODS: Eighty-four patients requiring ureteral stent placement after retrograde intrarenal surgery (RIRS) were enrolled. After stent removal on postoperative day 14, the encrustation volume on the stent surface was measured by micro-computed tomography. Of the 84 patients, 71 were eligible for this study, excluding seven patients with no encrustation, two patients with uric acid (1 patient) and cystine (1 patient), and four patients with no available data. The encrustation volume was evaluated by micro-CT, and the stone components and the component ratio were determined using infrared spectroscopy. RESULTS: All included patients had encrustation in the inner lumen of the stent. Compared to this, encrustation on the outer surface was observed only in 3 (4.2%) patients (p <0.001). Sixty-seven patients (94%) had calcium oxalate as the primary stone component, 42 (62%) of whom had pure calcium oxalate. Four patients (6%) had pure calcium phosphate as the primary stone component, three of whom had mixed stone with calcium phosphate. Cases with calcium oxalate showed a higher prevalence of stone components than those with calcium phosphate (p <0.001). However, cases with calcium phosphate stone had a significantly greater median inner encrustation volume compared to those with calcium oxalate stone (3.66 mm3 vs. 1.11 mm3; p <0.001). There was no difference observed in the encrustation volume on the outer surface between the two stone components (p=0.86). In multivariate analysis, crystalluria (p=0.013) and primary calcium phosphate component (p <0.001) were significantly associated with the increased total encrustation volume on the stent. CONCLUSIONS: This study revealed that the encrustation volume on the stent was significantly greater for calcium phosphate compared to calcium oxalate with the short-term indwelling ureteral stent. Thus, early stent removal may be recommended for patients with calcium phosphate stones. Source of Funding: No source of funding © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e840 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Shinji Fukui More articles by this author Takashi Yoshida More articles by this author Kuniko Takemoto More articles by this author Hidefumi Kinoshita More articles by this author Expand All Advertisement PDF DownloadLoading ...

Stent Graft Placement by Pseudoaneurysm of the Hepatic Arteries: Efficacy and Patency Rate in Follow-up

PurposeTo investigate efficacy and patency status of stent graft implantation in the treatment of hepatic artery pseudoaneurysm.Materials and MethodsA retrospective analysis of patients who had undergone endovascular treatment of hepatic artery pseudoaneurysms between 2011 and 2020 was performed. Medical records were examined to obtain patients’ surgical histories and to screen for active bleeding. Angiographic data on vascular access, target vessel, material used and technical success, defined as the exclusion of the pseudoaneurysm by means of a stent graft with sufficient control of bleeding, were collected. Vessel patency at follow-up CT was analyzed and classified as short-term (< 6 weeks), mid-term (between 6 weeks and 1 year), and long-term patency (> 1 year). In case of stent occlusion, collateralization and signs of hepatic hypoperfusion were examined.ResultsIn total, 30 patients were included and of these, 25 and 5 had undergone stent graft implantation and coiling, respectively. In patients with implanted stent grafts, technical success was achieved in 23/25 patients (92%). Follow-up CT scans were available in 16 patients, showing stent graft patency in 9/16 patients (56%). Short-term, mid-term, and long-term short-term stent patency was found in 81% (13/16), 40% (4/10), and 50% (2/4). In patients with stent graft occlusion, 86% (6/7) exhibited maintenance of arterial liver perfusion via collaterals and 14% (1/7) exhibited liver abscess during follow-up.ConclusionStent graft provides an effective treatment for hepatic artery pseudoaneurysms. Even though patency rates decreased as a function of time, stent occlusion was mainly asymptomatic due to sufficient collateralization.

Short-term stent strut coverage: optical coherence tomography vs high-definition intravascular ultrasound.

Short-term stent strut coverage: optical coherence tomography vs high-definition intravascular ultrasound.

A new choice of stent for transjugular intrahepatic portosystemic shunt creation: Viabahn ePTFE covered stent/bare metal stent combination

ObjectivesTo compare the clinical outcomes in terms of structure and function between the insertion of a transjugular intrahepatic portosystemic shunt (TIPS) created with the Viabahn ePTFE covered stent/bare metal stent (BMS) combination and the Fluency ePTFE covered stent/BMS combination. MethodsA total of 101 consecutive patients who received a TIPS from February 2016 to August 2018 in our center were retrospectively analyzed. Sixty-four subjects were enrolled in the Viabahn group and 37 were enrolled in the Fluency group. The geometry characteristics of the TIPS were calculated, and the associated occurrence of shunt dysfunction, survival, overt hepatic encephalopathy, and variceal rebleeding were evaluated. ResultsThe technical success rate was 100%. After the insertion of the TIPS, the rate of shunt dysfunction during the first 3 months was significantly different between the Viabahn and Fluency groups (1.6% and 13.5%, respectively; p ​= ​0.024). Multivariate analysis indicated that the angle of portal venous inflow (α) was the only independent risk factor for shunt dysfunction (hazard ratio ​= ​1.060, 95% confidence interval ​= ​1.009–1.112, p ​= ​0.020). In addition, 3 months after the TIPS insertion, the α angle distinctly increased from 20.9° ​± ​14.3°–26.9° ​± ​20.1° (p ​= ​0.005) in the Fluency group but did not change significantly in the Viabahn group (from 21.9° ​± ​15.1°–22.9° ​± ​17.6°, p ​= ​0.798). ConclusionsShunt dysfunction was related to the α angle owing to the slight effect on the α angle after the implantation of the TIPS. The Viabahn ePTFE covered stent/BMS combination was more stable in structure and promised higher short-term stent patency compared with the Fluency ePTFE covered stent/BMS combination.

Stent Angioplasty for Acute Intracranial Atherosclerotic Occlusion After Failed Thrombectomy: A Single-Institution Series of 55 Patients

Analysis of safety and effectiveness of stent angioplasty for failure of thrombectomy in patients with acute intracranial atherosclerotic occlusion. Retrospective continuous analysis of the clinical data of 458 patients with acute stroke undergoing endovascular artery thrombectomy in Changhai Hospital of Second Military Medical University from May 2013 to February 2018. Patients with acute intracranial atherosclerotic occlusion treating with stent implantation were included and the safety and effectiveness of stent angioplasty was evaluated. There was successful stent release in 55 patients. There were 36 cases (65.5%) with occlusion located in the anterior circulation and 19 cases (34.5%) in the posterior circulation. Twenty patients underwent intravenous thrombolysis before surgery, and the time of admission to intravenous thrombolysis was (39.9 ± 13.2) minutes. Fifty-four patients (98.2%) achieved modified thrombolysis in cerebral infarction 2b-3 recanalization. The National Institutes of Health Stroke Scale score 2.0 (0.0,6.0) 7 days after surgery was significantly improved compared with the preoperative National Institutes of Health Stroke Scale score 12.5 (6.0-20.0) (Z= -4.073, P < 0.05). Intracranial hemorrhage occurred in 7 patients (12.7%) after surgery, among them, symptomatic intracranial hemorrhage occurred in 2 cases (3.6%). CTP examination of the skull 3-5 days after operation showed: Among 39 cases (70.9%): 33 cases (84.6%) were patency, 4 cases (10.3%) were occlusion, 2 cases (5.1%) were moderate stenosis, and 16 cases (29.1%) were not examined by computed tomography perfusion. Ninety-day follow-up showed that a total of 43 cases were followed up, and 12 cases were lost to follow-up. Thirty-four patients (79.1%) had a good prognosis 90 days after surgery (modified Rankin scale score 0-2) and 9 patients died (20.9%). When thrombectomy in patients with acute intracranial atherosclerotic occlusion fails, stent angioplasty is safe and effective; however, short-term stent reocclusion after surgery cannot be ignored. Because of the small sample size, larger multicenter clinical studies are needed to confirm this result.

Short-term external ureter stenting shows significant benefit in comparison to routine double-J stent placement after ureterorenoscopic stone extraction: A prospective randomized trial - the Fast track stent study (FaST).

To determine whether short-term stenting using an external ureter catheter following ureterorenoscopic stone extraction provides a better outcome in comparison to double-J stent ureteral stenting. Between August 2014 and August 2015, 141 patients initially managed with a double-J stent insertion were prospectively randomized to ureter catheter for 6 h vs double-J stent insertion for 5 days after stone extraction via ureteroscopy retrograde surgery (including flexible ureteroscopy retrograde surgery) in a single academic center. Endoscopic procedures were performed by nine surgeons. Exclusion criteria were acute urinary tract infection, a solitary kidney, or a stone mass more than 25 mm. Study endpoints were ureter-stent related symptoms and pain assessed by a validated questionnaire (ureteral stent symptom questionnaire) and visual analogue scale before and 4 weeks after surgery. Overall stone-free rate was more than 90%. Mean operative time was 24 min (range 5-63). Groups did not differ in terms of age, body mass index, and stone size. Patients who received short-term ureter catheter showed a significantly higher quality of life. In the ureter catheter group, the urinary index score (16.8 vs 27.8; P < 0.0001), the pain score (9.7 ± 1.3 vs 20.2 ± 1.5; P < 0.0001), and general health index (15.3 ± 0.7 vs 8.5 ± 0.6; P < 0.0001) were significantly lower. Consultation of a physician and antibiotic treatment were rarely needed (1.3 ± 0.1 vs 1.6 ± 0.1; P = 0.017). A short-term ureter catheter insertion for 6 h following ureteroscopy retrograde surgery stone removal is a safe procedure and superior to double-J stent insertion with regard to urinary symptoms, pain, quality of life, and stent related symptoms. Patients treated with a short-term ureter catheter recover more quickly, return to work earlier, and need less doctor visits. Most patients would recommend a ureter catheter, and would prefer this strategy in case of future stone treatments.

Outcome of flexible ureteroscopy for renal stone with overnight ureteral catheterization: a propensity score-matching analysis.

To evaluate the influence of overnight ureteral catheterization and determine if routine long-term post-stenting can be avoided in flexible ureterorenoscopy (fURS) procedure for kidney stone. Three hundred ninety-three patients who underwent single fURS for kidney stone between January 2013 and June 2016 at a single institute were retrospectively analyzed. The stone-free (SF) and perioperative complication rates in patients with routine long-term post-stenting after fURS (long-term stent group) were compared with those of patients with overnight ureteral catheterization (short-term stent group). Propensity score-matching analysis was used to adjust the difference in baseline preoperative parameters between the two groups. All preoperative parameters were chosen to develop the propensity score, and 74 patients in the short-term stent group were retrospectively matched with the patients in the long-term stent group at a 1:1 ratio. Patient characteristics included age, sex, side of involvement, height, body weight, body mass index, number of stone(s), stone volume, Hounsfield units of stone, preoperative white blood cell count, preoperative C-reactive protein, preoperative creatinine, pretreatment, pre-stenting, stenosis of the ureter, and procedure duration. The SF rates were 91.9 and 93.2% in the short-term and long-term stent groups, respectively. Perioperative complications were 14.9 and 12.2%. No difference was noted between the two groups in terms of SF and perioperative complication rates. Short-term post-stenting using overnight ureteral catheterization in uncomplicated cases after fURS for kidney stone was as effective as conventional long-term post-stenting in reducing postoperative complications. These preliminary data suggest the possibility that routine long-term post-stenting was unnecessary.

Short- versus Long-term Stenting in Children with Subglottic Stenosis Undergoing Laryngotracheal Reconstruction.

Objectives Suprastomal stents are routinely used in laryngotracheal reconstruction (LTR) to stabilize grafts and provide framework to sites of repair. However, the duration of stenting varies according to patient history and physician preference. We examined outcomes of short- versus long-term stenting in children with subglottic stenosis (SGS) undergoing LTR. Study Design Case series with chart review. Setting Tertiary care pediatric hospital. Subjects and Methods Thirty-six children <18 years old who underwent double-stage LTR for SGS from January 2012 to January 2015 were included. Demographic data, stenosis grade, and decannulation rates were compared between children with short-term stenting (≤21 days; n = 14) and those with long-term stenting (>21 days; n = 22). Results No significant difference between groups was seen for sex, age, race, or previous repair. Children in the short-term group were stented for 10.9 ± 4.9 days, compared with 44.0 ± 10.6 for those long-term ( P < .0001). A similar number of children with short- versus long-term stents had grade 3/4 stenosis preoperatively (71.4% vs 77.2%). Although time to decannulation was not significantly different, 72.7% of children with long-term stents were decannulated, as opposed to 35.7% with short-term stents ( P = .03). After adjusting for grade at surgery and age, children with long-term stents had 4.3 greater odds (95% CI, 1.0-18.3) of decannulation than children with short-term stents. Conclusions Children with long-term stenting were more likely to be successfully decannulated. Although long-term stenting improved outcomes for children with SGS, additional research is needed to better define ideal candidates for short- versus long-term stenting.

Sa1449 Short-Term Plastic Pancreatic Duct Stenting to Reduce Risk of Post Endoscopic Retrograde Cholangiopancreatography (ERCP) Pancreatitis (PEP): A Prospective Multi-National Registry

Sa1449 Short-Term Plastic Pancreatic Duct Stenting to Reduce Risk of Post Endoscopic Retrograde Cholangiopancreatography (ERCP) Pancreatitis (PEP): A Prospective Multi-National Registry

Transpapillary passage of a giant bile duct stone after endoscopic papillary large balloon dilation and short-term stenting

Transpapillary passage of a giant bile duct stone after endoscopic papillary large balloon dilation and short-term stenting

GS-002 - Multicenter randomized trial comparing short-term stenting versus balloon dilatation for dominant strictures in primary sclerosing cholangitis

GS-002 - Multicenter randomized trial comparing short-term stenting versus balloon dilatation for dominant strictures in primary sclerosing cholangitis

Outcomes of Stent Placement for Chronic Occlusion of a Filter-bearing Inferior Vena Cava in Patients with Severe Post-thrombotic Syndrome

To evaluate the technical aspects and short-term clinical results of stent placement for chronic occlusion of a filter-bearing inferior vena cava (IVC) in patients with severe post-thrombotic syndrome (PTS). A retrospective analysis of 24 patients with severe PTS associated with occlusion of a filter-bearing IVC treated by stent placement was conducted at a single institution from January 2010 to December 2014. Patient-reported quality of life and limb Villalta scores were evaluated before and after treatment by questionnaire and clinical examination, respectively. Stent patency was evaluated by duplex Doppler ultrasound, venography, or venous computed tomographic (CT) angiography. All patients tolerated the procedure well. Nineteen patients with filter-bearing IVC and bilateral iliofemoral occlusions were treated with "double-barrel" stents, two were treated with fenestrated stents, and the remaining three patients were treated by unilateral stent placement of the iliofemoral vein and filter-bearing IVC. Quality of life and Villalta scores were significantly improved (p<.001) after the procedure. The 1-year, and 2-year cumulative primary and secondary stent patency rates were 67% and 91%, and 45% and 77%, respectively. During a median follow-up period of 27 months (range 3-55 months), the cumulative rates of complete relief of pain (visual analog scale >5) and swelling (grade 3) were 77% (13 of 17 limbs at risk) and 75% (24 of 32 limbs at risk), respectively. There were 23 limbs with active ulcers and the cumulative rate of ulcer healing at 2 years was 73%. There were no cases of clinical bleeding, symptomatic pulmonary embolism, or mortality. Recanalization of an occluded IVC filter and stent placement through the filter is a feasible and safe method for management of PTS associated with filter-bearing IVC occlusions, with acceptable short-term stent patency and clinical results. However, close follow-up after procedure is necessary because of a relatively high re-occlusion rate.

Sa1218 Indications, Technical Success and Clinical Efficacy of Short-Term Plastic Pancreatic Duct Stenting: Interim Analysis of a Prospective Multi-National Registry

Sa1218 Indications, Technical Success and Clinical Efficacy of Short-Term Plastic Pancreatic Duct Stenting: Interim Analysis of a Prospective Multi-National Registry

Su1649 Algorithmic Approach Including Bile Aspiration to Decrease ERCP Associated Adverse Events in Primary Sclerosing Cholangitis

Su1646 Endoscopic Treatment of Dominant Biliary Strictures in Primary Sclerosing Cholangitis Patients: Comparison of Adverse Events Associated With Balloon Dilation With and Without Stenting Udayakumar Navaneethan, Ramprasad Jegadeesan*, Jeffrey Hammel, Madhusudhan R. Sanaka, John J. Vargo, Mansour A. Parsi Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH; Cleveland2Center for Interventional Endoscopy, Florida Hospital Institute for Minimally Invasive Therapy, Orlando, FL Background: Dominant biliary strictures occur commonly in patients with primary sclerosing cholangitis (PSC). The optimal endoscopic management of dominant strictures remains unclear and the comparative risk of adverse events associated with balloon dilation alone versus balloon dilation and short term stenting remains unknown. Aim: Our aim was to compare the rate of adverse events associated with balloon dilation alone versus balloon dilation followed by short term stenting (! 7 days) in PSC patients with dominant strictures. Methods: In this retrospective study, 298 patients with PSC were evaluated. Among these, patients who had undergone biliary balloon dilation and/or short term stent placement (! 7 days) for endoscopic treatment of dominant strictures were identified. Adverse events associated with endoscopic biliary balloon dilatation with and without short term stenting for management of dominant strictures were determined. Results: A total of 72 PSC patients (median age 52.6 years; interquartile range 42.5-64) with dominant strictures were identified. Fifteen patients (20.8%) were treated with endoscopic balloon dilation alone and 57 patients (79.2%) were treated with balloon dilation and stent placement. Both groups had comparable baseline characteristics such as age, symptoms, bilirubin levels and severity of PSC as determined by the Mayo PSC risk score. The median duration of follow-up after intervention was similar in both groups (49 months). The overall risk of adverse events with endoscopic retrograde cholangiopancreatography (ERCP) was 15.3% (nZ11). Six patients developed cholangitis which was the most common adverse event. None of the patients in the balloon dilation alone group developed adverse events in contrast to 19.3% of patients (nZ11) who had undergone balloon dilation and short term stenting. (p! 0.01) On multivariate analysis, only stent placement increased the risk of adverse event development. (Hazard ratio 1.86; 95% confidence interval [1.3-2.2], pZ0.02). Conclusions: In this study, even short term stenting after balloon dilation appeared to increase the overall risk of adverse events associated with treatment of dominant strictures in PSC patients. Randomized controlled trials are required to clarify the appropriate management of dominant strictures in PSC patients.

Su1646 Endoscopic Treatment of Dominant Biliary Strictures in Primary Sclerosing Cholangitis Patients: Comparison of Adverse Events Associated With Balloon Dilation With and Without Stenting

Su1646 Endoscopic Treatment of Dominant Biliary Strictures in Primary Sclerosing Cholangitis Patients: Comparison of Adverse Events Associated With Balloon Dilation With and Without Stenting Udayakumar Navaneethan, Ramprasad Jegadeesan*, Jeffrey Hammel, Madhusudhan R. Sanaka, John J. Vargo, Mansour A. Parsi Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH; Cleveland2Center for Interventional Endoscopy, Florida Hospital Institute for Minimally Invasive Therapy, Orlando, FL Background: Dominant biliary strictures occur commonly in patients with primary sclerosing cholangitis (PSC). The optimal endoscopic management of dominant strictures remains unclear and the comparative risk of adverse events associated with balloon dilation alone versus balloon dilation and short term stenting remains unknown. Aim: Our aim was to compare the rate of adverse events associated with balloon dilation alone versus balloon dilation followed by short term stenting (! 7 days) in PSC patients with dominant strictures. Methods: In this retrospective study, 298 patients with PSC were evaluated. Among these, patients who had undergone biliary balloon dilation and/or short term stent placement (! 7 days) for endoscopic treatment of dominant strictures were identified. Adverse events associated with endoscopic biliary balloon dilatation with and without short term stenting for management of dominant strictures were determined. Results: A total of 72 PSC patients (median age 52.6 years; interquartile range 42.5-64) with dominant strictures were identified. Fifteen patients (20.8%) were treated with endoscopic balloon dilation alone and 57 patients (79.2%) were treated with balloon dilation and stent placement. Both groups had comparable baseline characteristics such as age, symptoms, bilirubin levels and severity of PSC as determined by the Mayo PSC risk score. The median duration of follow-up after intervention was similar in both groups (49 months). The overall risk of adverse events with endoscopic retrograde cholangiopancreatography (ERCP) was 15.3% (nZ11). Six patients developed cholangitis which was the most common adverse event. None of the patients in the balloon dilation alone group developed adverse events in contrast to 19.3% of patients (nZ11) who had undergone balloon dilation and short term stenting. (p! 0.01) On multivariate analysis, only stent placement increased the risk of adverse event development. (Hazard ratio 1.86; 95% confidence interval [1.3-2.2], pZ0.02). Conclusions: In this study, even short term stenting after balloon dilation appeared to increase the overall risk of adverse events associated with treatment of dominant strictures in PSC patients. Randomized controlled trials are required to clarify the appropriate management of dominant strictures in PSC patients.

Mo1429 Short-Term Stenting With Short Fully Covered Self-Expandable Metal Biliary Stents for Post-Sphincterotomy Bleeding: Prospective Evaluation of Outcomes and Safety

Mo1429 Short-Term Stenting With Short Fully Covered Self-Expandable Metal Biliary Stents for Post-Sphincterotomy Bleeding: Prospective Evaluation of Outcomes and Safety

“FISHing” for an Accurate Diagnostic Test for Cholangiocarcinoma

Navaneethan U, Njei B, Venkatesh PG, et al. Fluorescence in situ hybridization for diagnosis of cholangiocarcinoma in primary sclerosing cholangitis: a systematic review and meta-analysis. Gastrointest Endosc 2014;79:943–950. Primary sclerosing cholangitis (PSC) is a chronic fibroinflammatory condition epitomized by progressive obliteration of the biliary tree. Although the natural history is variable, secondary biliary cirrhosis and end-stage liver failure occur in ≤50% of patients. In addition to managing the symptoms of PSC (predominantly pruritus and recurrent acute cholangitis), clinicians and patients remain vigilant for the interval development of cholangiocarcinoma (CCA), the lifetime incidence of which is 6%–20% (Am J Gastroenterol 2007;102:107–114). With improvements in cross-sectional imaging, PSC diagnosis and surveillance can be accomplished without the routine use of endoscopic retrograde cholangiopancreatography (ERCP). However, individuals with symptoms or signs of disease progression are referred for ERCP to palliate dominant strictures via dilation with or without short-term stent placement, and tissue sampling to evaluate for CCA. In this context, traditional intraductal tissue sampling techniques include brushings for cytology and forceps biopsies for histology. These modalities, alone or in combination, have limited (20%–60%) sensitivity for confirming CCA owing to the desmoplastic nature of these lesions, so clinicians cannot definitively “rule out” CCA with a negative result (Gastrointest Endosc 1995;42:565–572). Because cytopathology and histopathology are essentially qualitative tests that rely on a subjective assessment of cellular morphology, fluorescence in situ hybridization (FISH) has been studied as a supplementary assay. FISH is performed on intraductal brushing samples and uses fluorescently labeled probes that target the centromeres of chromosome 3, 7, and 17, as well as the 9p21 band (P16), evaluating for aneuploidy (abnormal number of chromosomes) by counting the number of affected cells; therefore, it is a quantitative test that requires theoretically fewer cells than cytopathology and removes the subjectivity associated with cytopathologic interpretation. Navaneethan et al (Gastrointest Endosc 2014;79: 943–950. e3) performed a structured metaanalysis of studies assessing the diagnostic utility of FISH in diagnosing CCA among patients with PSC. The authors included studies that allowed construction of a 2 × 2 contingency table with true-positive, false-negative, false-positive, and true-negative results. The authors used standard metaanalytic techniques to calculate composite sensitivity, specificity, likelihood ratios, and diagnostic odds ratio. There was moderate statistical heterogeneity among included studies, so the authors used a random effects model. A positive FISH for malignancy was defined as either polysomy (≥5 cells with gains of ≥2 of 4 probes) or trisomy/tetrasomy (trisomy, ≥10 cells with 3 copies of chromosome 7 or 3; tetrasomy, ≥10 cells with 4 copies of all probes). Eight studies of moderate to high methodologic quality (n = 828 individuals with PSC) met eligibility criteria. The pooled analysis from these studies demonstrated that FISH had an overall sensitivity of 68% (95% CI, 61%–74%), and specificity of 70% (95% CI, 66%–73%) for diagnosing CCA. The pooled positive likelihood ratio was 2.69 (95% CI, 1.84–3.97), and the negative likelihood ratio was 0.47 (95% CI, 0.39–0.58). The pooled odds ratio to detect CCA was 7.24 (95% CI, 3.93–13.36). The positive predictive value was 0.42 (95% CI, 0.36–0.47), and the negative predictive value was 0.87 (95% CI, 0.84–0.90). Stated alternatively, an individual with PSC and positive FISH had a 42% posttest probability of CCA and an 87% probability of being cancer free after negative FISH. Two of the included studies described the accuracy of FISH in the setting of negative cytology, reporting sensitivities of 57% (Gastroenterology 2006;131:1064–1072) and 60% (Am J Gastroenterol 2008;103:1263–1273) and specificities of 87% and 71%. This is the context in which FISH would be considered most valuable: when CCA is present, but routine cytology is negative for malignancy, FISH will be positive in ≤60% of cases. However, there remains a possibility that FISH is falsely positive, as reflected its lower specificity. The specificity of FISH seemed to be optimized (93%) by defining a positive test using polysomy alone (6 of 8 included studies), but this compromised the technique’s sensitivity (51%). The authors systematically removed 1 dataset at a time and recalculated their outcomes; no single dataset carried sufficient weight to influence significantly the pooled performance of FISH for diagnosing CCA in the setting of PSC.

Balloon dilatation for congenital nasal piriform aperture stenosis (CNPAS): A novel conservative technique

Congenital nasal piriform aperture stenosis (CNPAS) is an uncommon but important cause of nasal obstruction in infants. When it is severe, nasal decongestants or temporary nasal airway devices cannot address the problem adequately. The most common surgical technique used to treat the bony piriform aperture stenosis is the sublabial approach and drill-out of the nasal aperture followed by nasal stenting. This paper describes an infant with bilateral CNPAS who underwent a single successful balloon dilatation and short-term stenting of the nasal piriform apertures without the need for additional procedures.