Small Caliber Stents Research Articles

Retained Biliary Plastic Stents: Clinical Presentation, Complications, and Management

Abstract Background Biliary plastic stent (PS) mandates timely removal or replacement. The coronavirus disease 2019 (COVID-19) pandemic had affected the accessibility to medical therapy resulting in delay. We evaluated the burden of retained biliary PS, clinical profile, and impact of COVID-19 pandemic on stent retention. Material and Method Endoscopy database records between November 2019 and April 2022 were reviewed retrospectively to identify patients who had undergone stent exchange or removal > 3 months, that is, retained stents. Demography, comorbidity, indication and outcomes of index endoscopic retrograde cholangiopancreatography, size and duration of indwelling biliary PS, clinical presentation, imaging findings, cholangiography findings, stent-related complications, and stone formation and endotherapy details were noted. Results A total of 252 patients (100 [39.68%] males; median age 47 years [interquartile range [IQR] 32–56 years]) had common bile duct (CBD) stent retention. Median duration of retained CBD stent was 5 months (IQR = 4–6 months). Seventy (27.8%) were symptomatic with cholangitis (22, 8.7%), only jaundice (16, 6.3%), and only biliary abdominal pain (32, 12.7%). Sixty-one of 70 (87.1%) had abnormal imaging; 59/70 (84.3%) had new onset biliary stone or sludge (p ≤ 0.005). Stent retention > 6 months was significantly associated with stent fragmentation (0 vs. 20, p < 0.005) and choledocholithiasis (9 vs. 58, p < 0.005). Small caliber stent retention was more symptomatic (7 vs. 10 French [12/28 [42.85%] vs. 58/224 [25%], p = 0.049]). Univariate logistic regression analysis showed serum aspartate aminotransferase (AST), alkaline phosphatase levels, and CBD stent retention > 6 months were significantly associated with complications. On multivariate logistic regression analysis, serum AST > 2× upper limit normal (odds ratio [OR] = 5.487, 95% confidence interval [CI] = 3.1–9.9, p ≤ 0.005) and CBD stent retention > 6 months (OR = 8.6, CI = 3.1–23.92, p ≤ 0.005) were associated with complications. Out of 101 COVID-19 pandemic-attributed delay, 56/101 (55.44%) had symptomatic stent dysfunction. Endoscopic technical success rate was 97%, unsuccessful ones were due to large stones and impacted stents; with no mortality. Conclusion CBD PS stent retention, although mostly asymptomatic, can result in significant morbidity like jaundice, cholangitis, stent migration, fragmentation, or impaction in one-fourth of patients. Use of 7 Fr stent, retention duration > 6 months, abnormal imaging findings, and AST > twice the upper limit were significantly associated with complications. Endoscopic management was successful in 97% of patients.

Ureteral Stent Colonization and Urinary Tract Infection in Children Undergoing Minimally Invasive Pyeloplasty.

Minimally invasive pyeloplasty (MIP), namely, laparoscopic and robot-assisted interventions, has gained popularity in recent years. Double-J ureteral stents are frequently inserted during surgery. Foreign bodies in the urinary tract are considered as risk factor for developing urinary tract infection (UTI). This study aimed to specify the bacteria cultured from urine and stents responsible for UTI in children with indwelling ureteral stents undergoing MIP. We retrospectively reviewed medical records of 30 children (22 boys and 8 girls) who had undergone MIP between 2014 and 2017. Median age at surgery was 2.7 years (interquartile range [IQR]: 0.5-7.9). Urine cultures were obtained before surgery, before stent removal, 1 month after stent removal, and if UTI was suspected. Stents were removed 4 to 8 weeks after surgery and cultured. Patients' demographics, types of stents, and surgical details were recorded. Median stent indwelling time was 5.09 weeks (IQR: 4-6). Postoperative febrile UTI developed in 4/30 (13%) patients. Afebrile UTI occurred in another 4/30 (13%) patients. Stent cultures were positive in 19/30 (63%) patients. Stent and urinary cultures were identical in only one patient. Three of four patients with preoperative asymptomatic bacteriuria developed postoperative UTI. There was no association between UTI, gender, stent diameter, and duration of indwelling catheter. After MIP, febrile UTI and afebrile UTI occurred in about one quarter of patients. Pathogens isolated postsurgically from urinary cultures were unrelated to those colonizing the stents. Therefore, routine stent culturing is of low clinical significance. Moreover, small-caliber stents and longer indwelling periods were not risk factors for UTI. Optimizing antibiotic treatment for children with preoperative UTI may potentially prevent morbidity after surgery.

Baseline Serum sLOX-1 Concentrations Are Associated with 2-Year Major Adverse Cardiovascular and Cerebrovascular Events in Patients after Percutaneous Coronary Intervention

Background Soluble lectin-like oxidized low-density lipoprotein receptor-1 (sLOX-1) may be a potential biomarker of coronary artery disease (CAD) and stroke. Objective We aimed to investigate the association and prognostic value of elevated sLOX-1 concentrations with regard to long-term major adverse cardiovascular and cerebrovascular events (MACCEs) in patients with CAD undergoing primary percutaneous coronary intervention (PCI). Methods A total of 1011 patients were enrolled. Serum sLOX-1 concentrations were detected by the enzyme-linked immunosorbent assay (ELISA). Patients were followed for 2 years. Multivariate Cox regression and Kaplan-Meier survival curve were explored to assess the association between sLOX-1 and MACCEs. A receiver operating characteristic (ROC) curve was used to evaluate the diagnostic efficacy of sLOX-1. Results Two-year MACCEs were associated with serum sLOX-1 concentrations (HR 1.278, 95% CI 1.019-1.604, P = 0.034), left main disease (HR 2.938, 95% CI 1.246-6.925, P = 0.014), small-caliber stents used (HR 2.207, 95% CI 1.189-4.095, P = 0.012), and total stent length (HR 1.057, 95% CI 1.005-1.112, P = 0.030). Serum sLOX-1 concentration ≥ 1.10 ng/ml had maximum sensitivity and specificity in predicting the occurrence of 2-year MACCEs (P < 0.001). Patients with higher serum sLOX-1 concentrations showed a significantly higher incidence of MACCEs in the Kaplan-Meier curve (P < 0.001). The combination of any of the risk factors identified in multiple Cox regression was associated with a stepwise increase in MACCE rate (P < 0.001). Conclusions High baseline serum sLOX-1 concentration predicts 2-year MACCEs and shows an additional prognostic value to conventional risk factors in patients after primary PCI. sLOX-1 determination might play a complementary role in the risk stratification of patients with CAD treated with PCI.

Long Coronary Lesions Requiring Long Stents 20 mm. Analysis And Outcome In Patients Treated At Queen Alia Heart Institute

Objective: To determine the outcome after using long coronary stents >20 mm for long coronary lesions among patients treated at Queen Alia Heart Institute. Methods: This is a descriptive, and a retrospective non randomized study which was conducted at Queen Alia Heart Institute on 900 adult patients who underwent coronary angiography and intervention for either stable or unstable angina pectoris during the period between 2006 to 2011. Those patients had coronary intervention using a single long stent for each long lesion (>20 mm). Their follow up was analyzed and the outcome of these long stents was studied for in stent restenosis or in stent total occlusion in each specific coronary artery. A specially designed form was used to record the following data in the involved patients: age, gender, size and type of coronary stent (drug eluting or bare metal), the presence of diabetes mellitus, hypertension or hypercholesterolemia, and the status of the left ventricle. Results: The total number of patients who had long coronary stent intervention was 900 cases. Four hundred eighty patients (53.3%) had restudy cardiac catheterization within 6-8 months, which showed instent restenosis or instent total occlusion in 90 patients. Males constituted the majority (88.9%) of the affected patients. Smoking was the commonest (83.3%) factor associated with instent restenosis followed by Diabetes Mellitus (61.1%). About half the cases of long instent restenosis was found in left anterior descending artery, whereas right coronary artery and circumflex artery had almost equal ratios: 23.3% and 22.2% respectively. Long instent restenosis was commoner (33.3%) in ostial lesions and was the least (14.5%) in mid segment lesions. Bare metal stents were associated with the majority (77.8%) of cases of instent restenosis. About two thirds of the affected patients had small caliber stents (2.5 and 2.75 mm diameter). Conclusion: Instent restenosis or instent total occlusion in long coronary stents is a well recognized and not uncommon clinical entity. Men are more commonly affected than women. Ostial left anterior descending artery is more affected than other coronaries. Smoking, Diabetes Mellitus and the use of bare metal stents of small sized caliber (≤ 2.75 mm) were common in our study patient population and associated with increased incidence of long instent restenosis

Is Intraductal Papillary Mucinous Neoplasm Really a Risk Factor of Post-endoscopic Retrograde Cholangiopancreatography Pancreatitis after Pancreatic Stenting?

To the Editor We read with great interest the article by Ito et al. (1). It is extremely impressive and it is important to know that a risk factor of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) after intubation with a pancreatic stent in high-risk patients is an intraductal papillary mucinous neoplasm (IPMN). Although there are some previous reports on the prevention of PEP by a pancreatic stent (2, 3), the report by Ito et al. is of high value as it is the first report that clarified a risk factor of PEP after pancreatic duct stenting in patients at high risk in a multicenter setting. Herewith, we have the following questions: 1) Was there a bias of pancreatogram extent between patients with IPMN and those with other diseases? A pancreatogram for IPMN is generally obtained to ascertain communication between the IPMN and the pancreatic duct and to obtain pancreatic juice for cytology or biochemical examinations. Therefore, the extent of a pancreatogram in patients with IPMN may be stronger than that of patients with other diseases that could cause PEP. Meanwhile, we question the necessity of pancreatogram only to ascertain the communication between a cystic lesion and the main/branch pancreatic duct, because the communication is not necessarily revealed due to mucin. 2) What was the relationship between the opening of the orifice of the major papilla and the diameter of the MPD? Both would reflect viscosity of mucin. We think that the orifice would be open and that the diameter of MPD would be large if the mucin has a high viscosity. Therefore, we cannot understand that a small caliber stent would be occluded by mucin with high viscosity in a non-dilated duct at the pancreatic head as the authors discussed. 3) What was the frequency of guidewire mis-insertion into the pancreatic branch ducts which could lead to injury of the pancreatic duct and pancreatic parenchyma and PEP? We think it is important to know the frequency in a study on PEP. 4) What is the definition of difficult cannulation of the bile duct? This is critical information because difficult cannulation is related to PEP. As Ito et al. stated in their report, prospective randomized controlled trials for assessment of the efficacy of pancreatic stenting in patients at high risk or in patients with IPMN with as few limitations as possible are necessary.

VHM04 The Use of Small Caliber Covered Self-Expandable Metal Stents for Palliation of Severe Malignant Dysphagia

Self-expandable covered metal stents provide palliation for malignant dysphagia; however significant complication rates have been associated with currently available large diameter stents. We hypothesized that small caliber fully covered self-expandable metal stents (sccSEMS) would provide adequate palliation of dysphagia in the absence of major complications. Prospective observational study of patients presenting with severe malignant dysphagia from esophageal adenocarcinoma or squamous cell cancer. 38 sccSEMS with internal diameters ranging from 8 mm to 16 mm were placed in 23 patients with pre-stent luminal diameters of < 8 mm (n = 18) or 8-10 mm (n = 5). 8 tracheobronchial stents (shaft diameter 14 – 16 mm), 2 biliary stents (shaft diameter 8 – 10 mm), and 28 specially constructed esophageal stents (shaft diameter 12 – 16 mm) were placed. All stents were placed under direct endoscopic vision without fluoroscopic support. A small caliber pediatric endoscope (diameter 5.5mm) was used to traverse the malignant strictures in cases of near-total esophageal obstruction. The direct endoscopic placement of sccSEMS in patients presenting with severe malignant dysphagia was technically successful in all cases, significantly improved dysphagia scores, provided excellent durability, and resulted in no major complications. These small caliber stents may be viewed as an alternative to currently available stents in patients with severe malignant dysphagia.

Feasibility and safety of emergency ERCP and small-caliber pancreatic stenting as a bridging procedure in patients with acute biliary pancreatitis but difficult sphincterotomy

The aims of the present study were: (1) to assess the feasibility and safety of emergency endoscopic retrograde cholangiopancreatography (ERCP) and pancreatic duct (PD) stenting with small-caliber stents as a bridging procedure in acute biliary pancreatitis (ABP) patients in whom biliary endoscopic sphincterotomy (EST) proved difficult, failed or was contraindicated, and (2) to compare the clinical outcome of those patients having emergency ERCP with and without pancreatic stent. Eighty-seven consecutive patients with ABP were referred for emergency ERCP. In 60 of these ABP patients, ERCP, EST, and stone extraction (if necessary) were performed without PD stenting. In the remaining 27 patients, small-caliber (3-5 F, 4 cm) pancreatic stent insertion was initially applied. All patients were hospitalized for medical therapy and were followed up. The mean ages, the initial symptom-to-ERCP times, the Glasgow severity scores, and the peak amylase and CRP levels at initial presentation were not significantly different in the ERCP + EST with PD stent group versus the ERCP + EST without PD stent group. More importantly, the complication rate was significantly lower in the ERCP + EST with PD stent group versus the ERCP + EST without PD stent group (7.4% vs. 25%); while the mortality rates (0% vs. 6.7%) were comparable, reasonably low, and demonstrated no statistically significant differences. Temporary PD stenting with small-caliber stents is a safe and effective procedure that may afford sufficient PD decompression to reverse the process of ABP and serve as a bridging procedure in severe ABP in patients with failed, complicated, or contraindicated biliary EST.

Endoscopic biliary sphincterotomy and small-caliber pancreatic stenting versus sphincterotomy alone in patients with acute gallstone pancreatitis – A prospective nonrandomized study

Introduction: Patients (pts) with acute biliary pancreatitis (ABP) may benefit from early endoscopic sphincterotomy (EST) and pancreatic ductal decompression. The aim of the present pilot study was to assess the feasibility and safety of emergency ERCP and pancreatic duct (PD) stenting with small-caliber stents in ABP patients (pts) after biliary EST.

SNARE‐OVER‐THE‐WIRE TECHNIQUE FOR SAFE EXCHANGE OF A STENT FOLLOWING ENDOSONOGRAPHY‐GUIDED BILIARY DRAINAGE

Endosonography-guided biliary drainage (ESBD) is a new option that allows establishment of biliary drainage. Due to the diameter of the working channel of an echoendoscope, it is necessary to replace a small caliber stent with a larger one to lessen the risk of stent occlusion. However, insertion of a guidewire into the bile duct via the hole of the sinus tract following direct removal of a previously placed stent is not always possible, resulting in guidewire passage outside the fistula and bile leakage. Cannulation of the previously deployed stent, guidewire insertion into the bile duct via the cannula and the stent, and removal of the stent with the snare over the guidewire leaving the guidewire in place (the snare-over-the-wire technique [SOW]) for stent exchange following ESBD was attempted. Four patients who required stent exchange following ESBD were included in the present study to evaluate the feasibility and usefulness of SOW. SOW was successful in all the cases. A new stent was also successfully deployed over the guidewire in all the cases. No complications were encountered. The snare-over-the-wire technique is feasible and useful in stent exchange following ESBD for the reduction of the risk of guidewire migration.

Endoscopic management of biliary fistulas with small caliber stents.

Biliary fistulas have in the past been managed by a variety of methods, including surgical correction or endoscopic sphincterotomy. From 1984 to 1989, we used endoscopic indwelling biliary stents in seven consecutive patients with and without sphincterotomy and have attained fistula closure in all patients studied. The etiologies of the fistulous tracts varied, as did the type and number of stents used. The duration of time between stent placement and observed closure of the fistulous tracts ranged from 3 days to 5 months. Of note, all patients had a dramatic reduction of drainage within the first week. From our study we conclude that surgical correction of biliary fistulas is not required, that sphincterotomy is not mandatory for stent placement or fistula management in patients without distal obstruction, and that a single, small caliber stent alone may be effective.