Stent Decompression Research Articles

National rates and risk factors for stent failure after successful insertion in patients with obstructed, infected upper tract stones.

We report the incidence of stent failure, defined as the need for salvage percutaneous nephrostomy (PCN) placement following the placement of a ureteral stent, in patients with infection of an obstructed urinary tract secondary to urolithiasis. We also sought to identify risk factors associated with ureteral stent failure. Using the Nationwide Inpatient Sample, we used time trend analysis to examine the incidence of ureteral stent failure for infected urolithiasis, as well as the estimated annual percent change (EAPC) from 1998 to 2010. Logistic regression was performed to estimate the odds of stent failure based on patient and hospital characteristics. A total of 164 546 stents were placed during the study period. Of these, 97.8% resulted in successful decompression. The rates of successful stent decompression and stent failure increased over time (EAPC 14.05%, p < 0.001; EAPC 11.61%, p < 0.001). Middle-aged males with renal stones and acute kidney failure had higher odds of stent failure (p < 0.05). Salvage percutaneous nephrostomies were performed most frequently in urban teaching institutions (odds ratio [OR] 1.98, p = 0.001; OR 1.83, p < 0.001). Ureteral stent decompression for an infected obstructed urinary tract secondary to urolithiasis is almost always effective. For a small proportion of patients, stent failure will occur and will require the placement of a nephrostomy tube. Stent failure is associated with male gender, stone location, and renal failure. Salvage percutaneous nephrostomies for these patients occur most frequently in urban teaching hospitals. Of note, this study was limited by the presumption that coding for a PCN after stent placement indicated stent failure, which could not be verified because of the inherent limitations of the dataset.

Use of biliary stent in laparoscopic common bile duct exploration.

It is well supported in the literature that laparoscopic common bile duct exploration (LCBDE) for choledocholithiasis has equal efficacy when compared to ERCP followed by laparoscopic cholecystectomy. Decompression after supra-duodenal choledochotomy is common practice as it reduced the risk of bile leaks. We conducted a prospective non-randomized study to compare outcomes and length of stay in patients undergoing biliary stent insertion versus T-tube drainage following LCBDE via choledochotomy. The study involved 116 patients with choledocholithiasis who underwent LCBDE and decompression of the biliary system by either ante-grade biliary stent or T-tube insertion. A 7 French straight/duodenal curve biliary Diagmed™ stent (9-11 cm) was placed in 82 patients (Biliary Stent Group). T-tube insertion was used for 34 patients (T-tube group). The length of hospital stay and complications for the selected patients were recorded. All trans-cystic common bile duct explorations were excluded from the study. The mean hospital stay for patients who underwent ante-grade biliary stent or T-tube insertion after LBCDE were 1 and 3.4 days, respectively. This is a statistically significant result with a p value of less than 0.001. Of the T-tube group, two patients required laparoscopic washout due to bile leaks, one had ongoing biliary stasis and one reported ongoing pain whilst the T-tube was in situ. A complication rate of 11.2%, this was a significant finding. There were no complications or concerns reported for the Biliary Stent Group. Our results show that there is a significant reduction in length of hospital stay and morbidity for patients that have ante-grade biliary stent decompression of the CBD post laparoscopic choledochotomy when compared T-tube drainage. This implies that ante-grade biliary stent insertion is likely to reduce costs and increase overall patient satisfaction. We support the use of ante-grade biliary stent insertion during LCBDE when primary closure is not preferred.

Preoperative intestinal stent decompression with primary laparoscopic surgery to treat left-sided colorectal cancer with obstruction: a report of 21 cases.

ObjectiveThis work aimed to study the safety and efficacy of preoperative intestinal stent decompression combined with laparoscopic surgery to treat left-sided colorectal cancer with obstruction (LCCO).MethodsRetrospective analysis was conducted on data obtained from 21 LCCO patients admitted to The First Affiliated Hospital of Zhejiang Chinese Medicine University during March 2008 and December 2011. To remove the intestinal obstruction, preoperative intestinal stent placement under colonoscopic guidance was performed. Approximately 7 to 10 days after the operation, laparoscopic radical surgery of colorectal cancer was conducted.ResultsAmong the 21 cases studied, laparoscopic surgery was successful in 20 patients. Emergent laparotomy was conducted in one patient because of tumor invasion in the ureter. The duration of the operation ranged from 180 to 320 min, and the average time was 220 min. The recovery time for bowel function ranged from 2 to 5 days with an average time of 3 days. Postoperative infection of the incision occurred in one case. No anastomotic leakage was observed in any of the cases.ConclusionPreoperative intestinal stent decompression, combined with primary stage laparoscopic surgery, is a safe and effective method for the treatment of LCCO.

Short and Long-Term Outcomes of Patients Sustaining Iatrogenic Endoscopic Colorectal Perforations

Purpose: Although risk factors for iatrogenic endoscopic perforations have been well delineated, little is known about the outcome of such patients once they leave the endoscopy suite. The purpose of this study was to examine the management and results of patients who sustained endoscopic colorectal perforations at a tertiary care teaching center. Methods: A retrospective review was conducted of all patients who were diagnosed with colorectal perforations following endoscopy over a 10 year period at Kaiser Permanente, Los Angeles. Endoscopy reports and patient's inpatient and outpatient medical records were reviewed. Variables analyzed included demographics, location of perforation, timing of presentation, surgical management, post-operative complications, and mortality. Results: During the study period a total of 72071 flexible endoscopies were performed [colonoscopy 41115 (57%), sigmoidoscopy 30956 (43%)]. Perforation occurred in 26 patients (0.04%). 24 patients had complete records and were the focus of this study. Mean age was 68 years with male predominance (63%). Majority of procedures (71%) were outpatient and 29% were inpatient (5 patients for bleeding, 2 patients for stent decompression). Most common location of perforation was sigmoid or rectosigmoid (50%). Majority of perforations (67%) presented within 24 hours of endoscopy, 17% > 24 hours, and 17% were recognized at time of procedure. 22 patients (92%) underwent surgical intervention and only 2 (8%) were managed conservatively. Median size of perforation was 2 cm [range 1-8 cm]. Operative interventions consisted of primary repair in 18 (75%) and colectomy in 4 (17%). 5 patients (21%) received colostomy. 30-day mortality was 21% and no death was noted at 90-days. Mortality was 0%, 50%, and 100% in patients with ASA class I-II, III, IV, respectively. Post-operative morbidity rate was 58% with septic complications being most common (54%) followed by cardiac (17%), and pulmonary (13%). Conclusion: Iatrogenic endoscopic colorectal perforation is a rare event in a high volume endoscopy suite. Most patients require surgical intervention which carries a significant risk of mortality especially in patients with ASA class III and IV. Post-operative complications are common and are often infection related.

Short-Term Outcome of Curative One-Stage Laparoscopic Resection for Obstructive Left-Sided Colon Cancers Followed by Stent Insertion: Comparative Study with Non-Obstructive Left-Sided Colon Cancers

Purpose: Laparoscopic surgery has been considered to be contraindicated for treating malignant colorectal obstruction. Stent insertion for obstructive colorectal cancer has recently allowed laparoscopic surgery to be performed by means of preoperative bowel decompression and bowel preparation. The aim of this study is to evaluate the safety and the feasibility of a one-stage laparoscopic resection for obstructive left-sided colon cancer after stent insertion by comparing the results to those for nonobstructive left-sided colon cancer. Methods: Between May 2006 and January 2009, a laparoscopic colorectal operation was performed on 18 consecutive patients with obstructive left-sided colon cancer after placement of a self-expandable stent by one colorectal surgeon, and the results were compared retrospectively to those for 43 patients with non-obstructive left-sided colon cancer who had undergone a laparoscopic procedure with the same surgeon. The collected data were the clinicopathologic characteristics, the perioperative complications, the oncologic outcomes, the postoperative recovery results, and the survival rate. Results: The obstructive left-sided colon cancer group had significant benefits in retrieved lymph nodes (18.8 ±5.3 vs. 14.0± 8.7, P=0.036), and distal resection margin (5.5±3.0 cm vs. 3.6±2.4 cm, P=0.011). There were no significant differences in other clinicopathological characteristics and oncologic outcomes, including the overall 3-yr survival rate, between the two groups. Conclusion: Preoperative stent decompression followed by a laparoscopic colorectal resection is a safe and feasible option for treating obstructive left-sided colon cancer. A further large-scale prospective study should be performed to evaluate the long-term outcome of a one-stage laparoscopic resection using stent insertion in cases of obstructive left-sided colon cancer.

Klatskin-like Biliary Sarcoidosis

Purpose: Clinical Vignette: Sarcoidosis is a multisystem granulomatous disease of unknown etiology that presents most often in young adults with hilar adenopathy, pulmonary infiltrates, skin or eye lesions. Hepatobiliary involvement is asymptomatic in most, with non-caseating granulomas seen often. Cholestatic hepatitis with liver chemistry resembling PBC or PSC has been described. Intra-hepatic cholestasis, hepatosplenomegaly, pre-sinusoidal portal hypertension, portal fibrosis, and cirrhosis may be seen. Abnormalities of the large bile ducts and extra-hepatic tree is rarely seen, and we describe a Klatskin-like biliary confluence granulomatous obstruction that responded to balloon dilation, stenting, and corticosteroid therapy. Case: A 38 yr. old caucasian female presented with painless jaundice. She complained of pruritus, weakness, fatigue, dark urine and malaise. Initial labs: Bilirubin 11, AST-107, ALT-92, GGT-431 (Nl 15–85), Alk. Phos-635, CEA-1.2, Nl p-ANCA, Nl Ig's, ACE-28 (Nl 8–21); ANA, AMA, copper, Ferritin were WNL. U.S. revealed intra-hepatic duct dilations; CT and MRCP with confluence region mass effect with marked proximal ductal dilation. A 3 cm portacaval node was noted; ERCP with Spyglass cholangioscopy displayed a tight confluence stricture, with extension into the right hepatic system; After balloon dilation of both right and left ducts, cholangioscopy revealed a nodular duct wall and brushings and directed biopsy bites were collected. Histology from the confluence revealed non-caseating granulomas with chronic cholangitis; No malignancy was detected. A 10 F stent was placed into the dominant right system and the bilirubin fell from 17 to 11 mg/dl overnite. The pateint was treated with Urso and 40 mg of Prednisone. Follow-up 2 weeks later: Bili.-1.5, GGT-135, ALT-48. Conclusions: Sarcoidosis is a chronic granulomatous disease that may present in young adults as a hepatocellular or cholestatic process. Extra-hepatic biliary obstruction may result from peri-ductal adenopathy or from ductal infiltration. Cholangioscopy may prove beneficial in directing biopsies and/or brushings to rule out carcinoma. Biliary sarcoidosis appears to be exquisitely sensitive to biliary stent decompression and corticosteroids.

Idiopathic retroperitoneal fibrosis: a rare disease to be treated by an internist

The idiopathic retroperitoneal fibrosis is a rare and complex disease that usually is treated by urologist, being its most common clinical presentation ‘‘back pain with homolateral hydronephrosis.’’ However, the main therapy is a medical treatment—immunosuppressive and/or antifibrogenic—that must be started as soon as possible; usually, instead, only intervention with decompression of the urinal obstruction is performed, and the necessary pharmacological therapy is often postponed or, in the worst cases, ignored. Moreover, we have recently pointed out that an experienced internist can provide a more accurate and not invasive diagnosis compared to the typical surgical one [1]. We present the case of a patient affected by idiopathic retroperitoneal fibrosis, hospitalised by the internal medicine staff after the wrong treatment implemented by urologists. A 53-year-old man was admitted to our hospital—in the internal medicine department—after receiving a bilateral nephrostomy 50 days earlier in another hospital. The state of his health was generally good. The urology department where the patient had been previously hospitalised diagnosed a bilateral hydronephrosis caused by suspected idiopathic retroperitoneal fibrosis. A guided CT-scan biopsy seemed to confirm the diagnostic hypothesis, and the urologist, after an unsuccessful stent decompression, performed a bilateral nephrostomy. The patient did not receive any program of drug therapy. After the patient was admitted to our department, we confirmed the diagnostic hypothesis through data derived from history, symptoms, physical examination, thoracicabdominal NMR and biochemical tests (ANA, antidsDNA, ENA, ANCA, ASMA, serum rheumatoid factor, anti-TPO antibodies, ACE, PPD skin testing), while we did not perform gallium-67 scan and/or PET-scan in order to avoid any delay in the beginning of the medical treatment. Through these tests, we could exclude cancer, autoimmune and granulomatous diseases. The negative results of the acute-phase reactants (i.e. PCR and ESR), although not very specific, indicated a limited activity of the disease. The NMR, in the T2-weighted images (Fig. 1), confirmed this hypothesis and suggested a pattern of disease less responsive to an immunosuppressive approach. However, we decided to start the immunosuppressive drug therapy, prednisone and azathioprine. After 40 days, because the dimensions of the fibrous mass showed no reduction, we transferred the patient to the urology department where he received bilateral intraperitonealisation of ureters and sealing of both nephrostomies. One month later, we started a tamoxifen therapy, and in 3 months we obtained the reduction of more than 50% of the fibrous mass. The idiopathic retroperitoneal fibrosis [2] is a disease observed and treated by urologists and less frequently by internists, because of its clinical presentation with a monoor bilateral hydronephrosis. However, it is possible to treat the disease with an appropriate and timely pharmacological therapy rather than with an invasive strategy as often performed by urologists. Indeed the diagnostic techniques for imaging, especially NMR and/or gallium scintigraphy and/or PET scan, together with an accurate clinical assessment and some other tests—which can identify neoplasia, auto-immune and granulomatous diseases—allow to obtain a deductive and not invasive diagnosis. Nevertheless, the disease appears more easily curable when the drug therapy is started A. Artom (&) M. Uccelli P. Artom Division of Internal Medicine, Santa Corona Hospital, 17027 Pietra Ligure (SV), Italy e-mail: alberto.artom@ospedalesantacorona.it

One-Stage Laparoscopic Colorectal Resection after Placement of Self-Expanding Metallic Stents for Colorectal Obstruction

The aim of this study was to assess the clinical outcomes of self-expandable metallic stents placing followed by laparoscopic resection and primary anastomosis for the treatment of acute colonic obstruction. From January 2003 to December 2004, 14 patients diagnosed with acute and complete colonic obstruction were treated with endoscopic colonic stenting as a bridge to an elective 1-stage laparoscopic resection. Three patients who underwent a successful stent insertion but had an inoperable tumor were excluded from the analyzed data. Ninety-three percent technical and clinical success was achieved. The stent insertion related perforation rate was 7% (1/14). The mean duration of stent insertion was approximately 1 hour and the mean time between the stent insertion and surgery was 6.2 days. Mean operating time was 132 +/- 38 minutes. No cases required conversion to laparotomy and there were no intraoperative complications. One case of anastomotic leakage was observed and treated by laparoscopic drainage and protective ileostomy. Ambulation time after operation was 1.8 +/- 0.6 days and total hospital stay length was 16.4 +/- 5.0 days. During a period of 11 +/- 7 months of follow-up, neither recurrences nor port-site metastases were observed. The management of acute colonic obstruction using endoscopic stent decompression, followed by laparoscopic resection, had good results and can be considered feasible and safe. Larger comparative studies may help to establish this approach.

Challenge of percutaneous nephrolithotomy in patients with spinal neuropathy

To assess the technical difficulties, associated complications and stone clearance rates in patients with spinal neuropathy undergoing percutaneous nephrolithotomy. Twenty-nine patients with spinal neuropathy underwent percutaneous nephrolithotomy in the two centers studied between October 1995 and January 2002. They were nine patients with traumatic spinal cord injury, 10 patients with spina bifida and 10 with other heterogeneous causes for their spinal neuropathy. The group included 12 men and 17 women, with an average age of 44 years (14-80). Patients' medical records were reviewed retrospectively for data relating to their renal lithiasis. A total of 39 percutaneous nephrolithotomy procedures were undertaken on 32 kidneys. Thirteen procedures were for staghorn calculi. Preoperatively, eight kidneys required nephrostomy and 5 J stent decompression. The average American Society of Anesthesiologists (ASA) score was 3, and one patient had percutaneous nephrolithotomy performed under local anaesthetic as the risk of general anaesthetic was felt to be too high. The associated morbidity and mortality in this group is significant. There were two postoperative deaths. Major complications were associated with three procedures, and consisted of seizures, aspiration pneumonia and pressure necrosis. Nine patients experienced minor complications including fever, hypotension and nephrostomy site leakage. Nine patients required intensive therapy unit care postoperatively and the average hospital stay for the group was 13.32 days. Only 18 (62%) patients were rendered stone-free from their initial percutaneous nephrolithotomy. Seven patients required a further procedure for stone clearance: four underwent extracorporeal shock-wave lithotripsy, two ureteroscopy and one nephrectomy. Patients with spinal neuropathy and renal lithiasis pose a significant operative challenge. Technical difficulties and potential complications should be considered carefully before undertaking percutaneous nephrolithotomy in these patients.

The Role of Ciprofloxacin in Prolonging Polyethylene Biliary Stent Patency: A MultiCenter, Double-Blinded Effectiveness Study

Plastic stents are the mainstay of the palliation of malignant jaundice but are complicated by recurrent obstruction. Previous trials have failed to demonstrate any improvement in patency with the use of antibiotics. Patients with malignant jaundice were randomized in a double-blind fashion, after polyethylene stent insertion, to receive ciprofloxacin or placebo. After successful stent decompression, there were 50 patients in the treatment arm and 44 in the placebo. There were 14 (33%) episodes of stent occlusion in the ciprofloxacin group versus 23 (49%) in placebo (chi(2) test, P=0.115). There was no significant difference in patency (log-rank test, P=0.17). There were significantly fewer episodes of cholangitis with ciprofloxacin: 10 (23%) versus 21 (42%) in the placebo (P=0.047). The ciprofloxacin group also demonstrated a significant improvement in the Social Function domain of the SF-36 Quality of Life Survey at 1 month (paired T test, P=0.03). The other domains of the SF-36 were not different, nor was survival (log rank, P=0.80). There is insufficient evidence to show that prophylactic ciprofloxacin can prolong plastic biliary stent patency. The observed trends suggest that ciprofloxacin significantly decreases the incidence of cholangitis and results in improvements in certain aspects of quality of life.

Malignant colonic obstruction managed by endoscopic stent decompression followed by laparoscopic resections.

Acute left-side colonic obstruction is a surgical emergency whose management is controversial. Recently metallic expandable stents have been used to relieve obstruction either to palliate the condition or to prepare for an elective surgical resection. We propose a new minimally invasive therapeutic strategy for the management of malignant colonic obstructions: emergency endoscopic stenting followed by elective laparoscopic one-stage resection. The first four cases are presented. The stents were positioned successfully in all cases, and all the patients had an immediate restoration of bowel functions. After a period that varied from 4 to 5 days, they underwent a one-stage laparoscopic resection and were discharged 5 to 7 days after the operation. There were no postoperative complications. Malignant colonic obstruction can be managed by a sequential minimally invasive endolaparoscopic approach with an excellent postoperative outcome, good patient comfort, and a short hospital stay without the need for diverting stomas. A study involving a larger number of patients is needed to determine whether this approach is superior to traditional open surgery in terms of morbidity, mortality, quality of life, and recurrences.

Laparoscopic management and clinical outcome of emphysematous cholecystitis.

As opposed to acute, chronic, and acalculus cholecystitis, emphysematous cholecystitis (EC) is associated with significant morbidity and mortality. Only a few studies have specifically reviewed the operative management and clinical outcome of EC. This study documents the operative management and clinical outcome of EC at the Cleveland Clinic Foundation. Between January 1996 and June 1999, 18 consecutive patients underwent cholecystectomy for emphysematous cholecystitis at our institution. All charts were reviewed retrospectively, and patients undergoing concurrent procedures were excluded. Mean values +/- standard deviation (SD) of the mean were calculated for patient demographics, preoperative white blood cell count (WBC), bilirubin, alkaline phosphatase, and length of hospital stay. Operative procedure (laparoscopic, converted, or open), preoperative imaging studies, operative time, ICU stay, morbidity, and mortality were reviewed. Patients presented with a mean age of 53.4 years (range, 18-80) and a male/female ratio of 3.5 (14/4). There were no differences between groups in terms of patient demographics. Mean WBC on admission was 14.2 K/mL (range, 5.4-19.7). Mean alkaline phosphatase and total bilirubin were 115 U/L (range, 45-428) and 1.4 mg/dl (range, 0.5-3.4), respectively. Thirteen patients (72%) were completed laparoscopically, two patients (11%) were converted to an open procedure, and three patients (17%) had open surgery. Overall mean length of hospital stay was 5 days (range, 1-18). Two patients from the open group ultimately died 1 year later due to progression of preexisting illness. One of these patients had congestive heart failure and chronic renal failure; the other had metastatic malignant melanoma. None of the patients died in the immediate perioperative period. There were five complications (27.8%). Two patients presented with bleeding secondary to heparin and coumadin therapy. One developed sepsis, and another developed leakage from the cystic duct stump, necessitating an endoscopic retrograde cholangiopancreatogram (ERCP) with stent decompression. The fifth complication, ileus, required readmission 3 days postoperatively, but the patient responded to conservative management. Complications were evenly distributed between the three groups. There were two complications in the laparoscopic group, two in the open group, and one in the conversion group. All other patients were alive at the time of this publication. Using current techniques, patients with EC can be managed successfully utilizing laparoscopy. Morbidity and mortality appear to be slightly higher than published reports for acute, chronic, and acalculus cholecystitis. Conversion rates are comparable to patients with acute and chronic cholecystitis who undergo laparoscopic cholecystectomy. Based on these data, laparoscopic cholecystectomy should be considered the first-line treatment for patients with known or suspected EC.