Stent Exchange Research Articles

Use of metallic and polymeric ureteral stents in malignant ureteral obstruction.

BackgroundMalignant ureteral obstruction (MUO) is often caused by advanced intra‐abdominal cancers. Effective management must be attempted, but the treatment policy is unclear. Metallic ureteral stents are one of the latest options in managing MUO. Metallic ureteral stents are superior to traditional polyurethane stents. The present study retrospectively reviewed our four institutions’ experiences with treating MUO using metallic ureteral stent.MethodsA total of 45 patients who required metallic ureteral stent placement for MUO at Yokohama City University Medical Center (Yokohama, JAPAN) between January 2014 and May 2016 were analyzed. We defined stent failure as having to change the ureteral stent before the scheduled ureteral stent exchange time or having to perform percutaneous nephrostomy (PCN). Complications were defined as an unscheduled hospital visit or hospitalization caused by incompatibility, infection, and pain of the metallic ureteral stent, etc., unrelated to the primary disease. We compared stent failure and the overall survival (OS) between metallic and polymeric ureteral stents. To evaluate the workload of the medical staff, we used the NASA Task Load Index (NASA‐TLX) in a total of 11 urologists.ResultsDuring the observation period, 8 (17.8%) patients in the metallic ureteral stent group and 10 (27.8%) in the control group developed stent failure. Complications were noted in 14 (31.1%) patients in the metallic ureteral stent group and 15 (41.7%) patients in the control group. A Kaplan–Meier analysis and log‐rank test showed no significant differences between two groups in the overall survival (P = 0.673). One or more complications developed in 19 (32.2%) patients in the metallic ureteral stent group and 18 (38.3%) patients in the control group (P = 0.409). Renal dysfunction after the replacement of the ureteral stent developed in 9 (15.3%) patients in the metallic ureteral stent group and 14 (29.8%) patients in the control group. No patients developed a urinary tract infection (UTI) that required hospitalization in the metallic ureteral stent group, whereas 3 (6.4%) patients in the control group had a UTI that was treated with hospitalization. The average workload score in the six subscales was analyzed, and the scores for mental demand and performance were higher in the metallic ureteral stent group, although there was no significant difference between the metallic and polymeric ureteral stent groups.ConclusionsMetallic ureteral stents showed favorable ureteral stent patency and reduced the workload for urologists.

S1970 Utility of Covered Metal Stents in Esophageal Penetrating Injuries

INTRODUCTION: Management of esophageal perforations and leaks is traditionally managed via a surgical approach, however, here we show that self-expanding metal stents (SEMS) can be used to successfully treat esophageal injuries. CASE DESCRIPTION/METHODS: Case 1: A 27-yo man presented for GSW to the chest and went for surgical repair of the proximal esophagus. The esophageal defect was oversewn, but on day 7 an esophagram revealed an anterior leak. On EGD, there were 2 medium-sized perforations 30 cm from the incisors that were covered with a 12 cm × 20 mm fully covered stent under fluoroscopic guidance and anchored with two hemostatic clips. One week later the stent was exchanged because one perforation was still present. At two-weeks after the first EGD, the perforations had completely healed that was confirmed with esophagram. Case 2: A 21 year-old-woman presented for GSW to the neck who was found to have a T1 spinal cord injury with severe damage to the soft tissue. An esophageal perforation was found on a later esophagram and surgical repair failed to close the leak. EGD showed a perforation at 20 cm from the incisors that was treated with a 12 cm × 20 mm fully covered stent under fluoroscopic guidance and anchored with two hemostatic clips. She had a repeat EGD with stent exchange, but at week-two the tract had epithelialized that was further treated with APC and closure with 3 clips. DISCUSSION: Esophageal perforations are a life-threatening complication. If not corrected within the first 24 hours, morbidity and mortality increases significantly due to increased risk for fulminant mediastinitis and pleural contamination.1 Successful closure of benign esophageal perforations with stents is approximately 82%-100%.1 In a study of 15 patients, early (∼45 minutes) versus late (∼123 hours) esophageal stenting decreased hospital stay to 5 days compared to 44 days in the late group related to complications of sepsis and multiorgan failure.4 Serious complications from esophageal stenting are stent perforation, stent-related bleeding, and strictures which occurred at 2%, 0.8%, and 3.2%, respectively. In that same study, 73/340 experienced stent migration.5 A study of 44 patients comparing rates of esophageal migration with and without anchoring clips, migration occurred in 3/23 patients with hemostatic clips versus 12/21 without hemostatic clips.6 Here are two cases of esophageal perforation where fully covered esophageal SEMS were used without complication of stent migration due to anchoring clips.Figure 1.: Esophageal perforation.Figure 2.: SEMS covering perforation.Figure 3.: Healed perforation after SEMS.

S3321 Recurrent Acute Pancreatitis Secondary to Pancreatic Divisum Anomaly

INTRODUCTION: Pancreatic divisum (PD) is a congenital malformation that occurs when the ventral and dorsal ducts of the pancreas fail to fuse. Inadequate drainage of pancreatic secretions from the minor papilla results in ductal distension and recurrent pancreatitis. We present a patient with PD who developed acute necrotizing pancreatitis (ANP) complicated by walled off pancreatic necrosis (WOPN). CASE DESCRIPTION/METHODS: 64-year-old female with history of chronic alcohol abuse and IBD presented with epigastric abdominal pain and emesis. Labs showed normal triglycerides, elevated lipase and amylase. Abdominal US ruled out gallstones. Abdominal CT showed pancreatic inflammation with several cystic-appearing fluid collections. She was treated conservatively. Repeat abdominal CT showed multiple increased peripancreatic fluid collections with mass effect on the stomach (Figure 1). Persistent abdominal pain led to ERCP which displayed complete PD and high-grade pancreatic duct fistula in the body and tail. Ventral and dorsal duct sphincterotomies were done with stent deployment in each duct. EUS revealed 3 peripancreatic fluid collections (consistent with WOPN); the largest was adjacent to the gastric antrum. Purulent drainage was noted after 3 cystogastrostomy incisions. Antibiotics were initiated. Patient eventually had recurrent pancreatitis, requiring repeat minor papilla sphincterotomy with dorsal pancreatic duct stent exchange. DISCUSSION: WOPN is a late complication of ANP, occurring more than 4 weeks after the initial attack. It can cause obstruction and fistula. Due to her PD anatomy, we suspect the patient had previous indolent acute pancreatitis episodes however they were falsely attributed to her IBD. Thus, delaying diagnosis of acute pancreatitis and leading to ANP and WOPN. The lifetime risk of pancreatitis in PD patients is similar to the general population. Consider PD in young, female patients in whom etiologies such as, gallstones and alcohol use, have been excluded. Alcohol abuse in context of her PD anatomy could have amplified our patient’s risk of acute pancreatitis. CT and MRI scans do not reliably detect PD thus ERCP remains the diagnostic test. Minor papilla sphincterotomy, papillary dilatation, stent insertion and pancreatic resection are treatment options. Since recurrent acute pancreatitis can lead to chronic pancreatitis, it is important to detect PD early. Follow up imaging in 3-6 months after pancreatitis resolution is vital, especially in patients with WOPN, to exclude neoplasm.Figure 1Figure 2.: Fig 1. and 2: CT abdomen and pelvis with contrast showing significantly compressed gastric lumen and multiloculated collections surrounding the pancreas, along the fundus of the stomach measuring 8 × 4.3 cm with mass effect, slightly inferiorly along the fundus and body measuring 7.7 × 4.2 cm, and along the antrum measuring 7.9 × 4.3 cm with surrounding fat stranding and mass effect.

The Role of Endoscopic Stent in Management of Postesophagectomy Leaks.

Anastomotic leak is a dreaded complication following esophagectomy. Conventional management for leaks includes invasive reoperation and even gastrointestinal diversion. The aim of this study was to examine our contemporary outcome of using endoscopic esophageal stenting as primary therapy for management of anastomotic leak following minimally invasive esophagectomy (MIE). We reviewed data on 11 patients who developed an esophageal leak following 111 MIE between January 2011 and December 2019. Of the 11 anastomotic leaks, 10 patients had an anastomotic disruption and underwent endoscopic esophageal stenting as primary therapy for management of leaks, while 1 patient had an anastomotic disruption complicated by an associated tracheoesophageal fistula that required surgical reoperation and subsequent colonic interposition. Main outcome measures focused on the 10 patients who were managed with endoscopic stenting, including length of hospital stay following leak management, need for thoracotomy or gastrointestinal diversion for leak, stent complications, and leak-associated mortality. Of the 10 patients who underwent endoscopic esophageal stenting as primary therapy for management of leaks, there were 8 males with a median age of 66years. The median time to diagnosis of anastomotic leak was 10days postoperatively. One of the ten patients also underwent percutaneous drain placement, while none of the patients required thoracotomy. Median duration of stent placement was 39 (range, 29-105) days. Median length of stay after stent placement was 10 (range, 4-43) days. The median number of stent exchange was 1 (range, 1-3) stent. Gastrointestinal continuity was maintained in all patients. The 90-day leak-associated mortality was 9.1% (1 of 11 patients). Endoscopic stenting is an effective primary therapy in the management of postesophagectomy leak and avoids the need for an invasive, reoperative thoracotomy or gastrointestinal diversion procedure.

Improved stability of steerable sheath access by femoro-femoral crossover wire in branched stent graft repair of complex thoraco-abdominal aortic aneurysms.

PurposeThe purpose of this study was to describe a technique to catheterize antegrade branches of a branched aortic endograft by using a steerable sheath stabilized by a through-and-through wire via a femoral access.TechniqueAfter implantation of a branched endovascular graft, a steerable 8.5 F sheath is advanced from the femoral access. After placing the sheath proximal to the branches, a 0.014″ through-and-through wire is established to the contralateral femoral access which is held under slight traction after the curved tip of the sheath is brought into the 180° position. Then catheterization, wire exchange and deployment of the bridging stent is done in standard fashion.ConclusionThe use of a through-and-through wire with a steerable sheath for retrograde femoral access adds stability and precision to this technique. It has the potential to reduce the risk of preoperative stroke in complex aortic endovascular repair by avoiding upper extremity access.

Ureteroarterial Fistula Presenting as Gross Hematuria during Routine Nephroureteral Stent Exchange

Ureteroarterial fistula (UAF) is an uncommon entity and underrecognized etiology of hematuria in patients with a history of pelvic malignancy, irradiation, and surgery. Herein we report two cases of UAF unexpectedly identified during routine nephroureteral stent exchanges which highlight salient points regarding diagnosis and management.

Uncoiling of a Cook Resonance Metallic Ureteral Stent.

Introduction and Background: The Cook Resonance® metallic ureteral stent's unique configuration allows adequate urine drainage while providing improved resistance to external ureteral compression. We report a case in which a stent broke and subsequently uncoiled during stent removal under cystoscopy. Case Presentation: A 46-year-old woman with a history of cervical carcinoma treated with radiation therapy and chemotherapy and bilateral ureteral strictures presented for cystoscopic removal of bilateral Cook Resonance ureteral stents. During removal of the right ureteral stent, a snap was felt with subsequent uncoiling of the stent. Firm tension to the inner wire and outside curls allowed eventual complete removal of the stent without any retained fragments. Discussion: The all-metal Cook Resonance stent is an attractive alternative to polymeric stents because of reduced frequency of stent exchange and resistance to external compression. However, the metal stent possesses risks such as increased urothelial hyperplasia and stent embedment.

Grade IV Renal Laceration in a 13-Year-Old Boy With Cross-fused Renal Ectopia

A 13-year-old boy presented with gross hematuria following a skateboarding accident and was found to have cross-fused renal ectopia of the left kidney with a grade IV right renal laceration and urinary extravasation. Despite a double-J ureteral stent, urinoma drain, and indwelling bladder catheter, his urinoma drain maintained high output. He underwent a ureteral stent exchange and upsizing. A percutaneous nephrostomy tube was subsequently placed for maximal urinary diversion, which ultimately led to the resolution in his urinary leak. This case highlights our endourologic approach to manage a severe urinary leak despite conservative measures in a pediatric patient with a renal anomaly.

Stenting Using the Rendezvous Technique for Postoperative Ureteral Complications in Cancer Patients.

This study aimed to retrospectively evaluate the safety and efficacy of ureteral stent placement using the rendezvous technique for the treatment of postoperative ureteral complications in cancer patients. From January 2005 to April 2015, 19 patients (2 men and 17 women; median age, 59; range, 42-79years old) with unilateral ureteral lesions (ureteral leakages in 6, strictures in 4, and both in 9) underwent ureteral stent placement using the rendezvous technique. Percutaneous nephrostomy was performed, and stent placement was attempted via antegrade and retrograde approaches. The technical success, procedure-related complications, and clinical success were retrospectively analyzed. The median follow-up period was 29.8months (range, 0.3-116.5months). The ureteral stent placement was successful in 17 out of 19 patients (89.5%). Double J ureteral stent was used in 6 patients, and straight catheter as an internal-external nephro-ureteral stent was used in 11 patients. The rendezvous technique was used in the retroperitoneal space and urinary tract in 6 and 11 patients, respectively. No major complications related to the rendezvous technique occurred. Finally, 4 patients achieved stent-free condition (21.1%), and periodic stent exchange was continued in 9 (47.4%). However, permanent external drainage and surgical reconstruction were needed in 4 (21.1%) and 2 (10.5%) patients, respectively. The final clinical success rate was 68.4% (13 out of 19 patients). Ureteral stent placement using the rendezvous technique for the treatment of postoperative ureteral complications in cancer patients is safe and may be alternative to permanent external drainage and invasive surgical reconstruction. Level 4, Case series.

Biodegradable Pancreatic and Biliary Stents—Still Searching For Disappearing Wonder?

AbstractBiodegradable stents hold considerable promise in the treatment of benign biliary or pancreatic diseases with the major advantage being avoidance of repeated interventions for stent removal or stent exchange. They have been confirmed to have good biocompatibility and current evidence shows acceptable rates of clinical efficacy and safety. In the current news and views, we discuss an interesting study that has evaluated a new type of biodegradable biliary and pancreatic stent (the Archimedes stent) in benign biliary and pancreatic diseases.

Su1446 TRANSPAPILLARY GALLBLADDER STENT PLACEMENT: EXPANDING TREATMENT OPTIONS FOR SYMPTOMATIC GALLSTONE DISEASE IN PATIENTS WITH CIRRHOSIS AWAITING LIVER TRANSPLANTATION

OBJECTIVES: The aim of this study was to evaluate clinical outcomes in patients with cirrhosis awaiting liver transplantation who underwent transpapillary gallbladder stent (TGS) placement for symptomatic gallstone disease. This retrospective study included patients with Child-Turcotte-Pugh class B or C cirrhosis with symptomatic gallstones causing biliary colic or acute cholecystitis. All patients were deemed to be high risk for cholecystectomy. The patients underwent endoscopic retrograde cholangiopancreatography (ERCP) with attempted TGS placement using a double pigtail plastic biliary stent. The database included patients from July 2008 to August 2019. Demographic variables, including age, sex, etiology of cirrhosis, number of procedures, Charlson Comorbidity Index (CCI), Model End Stage Liver Disease Sodium (MELD-Na) score were analyzed. A total of 20 patients with cirrhosis awaiting liver transplantation underwent ERCP for symptomatic gallstone disease (Table 1). Transpapillary biliary stent placement was technically successful in 90% (18 of 20) of patients. 13 of the 18 (72.2%) patients experienced complete resolution or clinical improvement in symptoms of gallbladder disease. Just over half (55%) of the patients developed recurrent symptoms at an average of 6.8 months, which were successfully managed with biliary stent exchange. Following TGS placement, 83% of patients had fewer emergency room visits for symptomatic gallstones (average decrease of 1.8 visits). 11% (2 of 18) patients ultimately required cholecystectomy due to persistent symptoms after TGS placement. Post-procedural complications were seen in 3 of the 18 (16.7%) patients including severe abdominal pain necessitating stent removal (n=1) and sepsis requiring hospitalization and antibiotics (n=2). There was no significant difference in age, burden of co-morbidities, MELD-Na score, or number of stent exchanges between patients who did not experience symptom improvement compared to those who did (p>0.05). Transpapillary gallbladder stent placement is safe and effective in managing symptomatic gallstone disease in patients with cirrhosis awaiting liver transplantation. Gallbladder stenting can be considered as an alternative treatment option in these patients who are at high surgical risk for cholecystectomy.

P0333ACQUIRED HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS IN A PATIENT WITH EMPHYSEMATOUS PYELONEPHRITIS AND SEVERE SEPSIS: A CASE REPORT

Abstract Introduction Hemophagocytic lymphohistiocytosis (HLH) is a rare disorder of uncontrolled immune activation.Incidence in the adult population remains unclear. Primary HLH is caused by genetic mutations affecting the cytotoxic function of T lymphocytes and natural killer (NK) cells and typically presents in young children. Secondary HLH occurs in the setting of infectious, malignant, rheumatologic, or metabolic conditions. Various infections have been described as triggers. The diagnosis of HLH is particularly challenging, as many features overlap with other causes of severe illness including sepsis and hematologic malignancy. Background 53-years-old male patient presented to a hospital elsewhere with complaints of fever, dysuria and malaise for 1 week. On evaluation, he was diagnosed as bilateral pyelonephritis with right sided emphysematous pyelonephritis,with urosepsis, acute kidney injury (AKI) on chronic kidney disease (CKD). Due to severe azotaemia and acidosis, patient required dialytic support (SLED) on 2 occasions. Subsequently, patient underwent bilateral DJ stenting, right renal papilla extraction and optical urethrotomy.Due to persistent fever and not improving general wellbeing patient was shifted to Star hospital for further management. Course in hospital Patient presented with severe sepsis and empiric antibiotic therapy started after sending appropriate cultures (date of admission 18.7.19). As cultures were suggestive of CRBSI, dialysis catheter removed and antibiotics continued. He improved initially, however he again had high-grade intermittent fever,then right sided PCNL and drainage of perinephric collection was done. Post procedure patient developed septic shock, hyperkalemia and acidemia. Left IJV dialysis catheter was placed and initiated on SLED. He underwent right nephrectomy and left DJ stent exchange in view of persistent fever despite using broad spectrum antibiotics and antifungals. X-ray chest showed pulmonary edema and 2D echo revealed global hypokinesia. Patient further deteriorated, vasopressor requirement increased and required intubation and mechanical ventilation on 1.8.19. Patient received GM-CSF in view of leukopenia. To look for other causes of non-responding sepsis, serum ferritin and interleukin 6 (IL-6) were tested. Ferritin was 4532 ng/ml& IL-6 was 531 pg/ml as on 1.8.19. Bone marrow aspiration and biopsy (3.8.19) revealed acquired hemophagocytosis,hence he was started on corticosteroids (1 mg/kg/day prednisolone equivalent) and other appropriate antibiotics continued. Gradually fever subsided and hemodynamic improved. As patient showed adequate respiratory attempts and acceptable oxygenation, he was extubated on 9.8.19. Patient remained on alternate day haemodialysis. Patent was discharged from hospital on 19.8.19 with tunnelled right IJV catheter for haemodialysis. Corticosteroids (prednisolone) tapered off gradually over a period of 8 weeks. After 8 weeks; patient remains dialysis dependant but back to work and routine life. Conclusion In events of non-responding sepsis, immunological disorders could be screened for and treated accordingly. Seemingly, treating immunological disorders and sepsis is seen antagonistic but might be mutually complementary as is seen in this particular case with acquired HLH where patient responded to immune suppression with corticosteroid. In literature search, we could not find association of HLH with emphysematous pyelonephritis. Hence, this could be a unique case of immune activation in a patient with complicated UTI, AKI and resulting in dialysis dependency. Moreover, antibiotic resistance and scarcity of new antibiotics are two more reasons to search for immune dysregulation in sepsis. As many of these cases could be immune dysregulation and not infection per se.

Intrabiliary Acetylcysteine Infusion for Biliary Obstruction in a Case of Chronic Pancreatitis with Pancreatic Head IPMN

AbstractSuccessful biliary drainage in case of intraductal papillary mucinous neoplasm (IPMN) with thick mucus by ERCP and internal drainage alone is usually inadequate. The mucolytic properties of acetylcysteine can offer a therapeutic benefit in this setting. We report a 50-year-old man with chronic pancreatitis and IPMN who had recurrent episodes of biliary obstruction due to mucous occlusion, despite multiple stent exchanges. A nasobiliary catheter was placed and infusion of acetylcysteine was performed which resulted in significant improvement of jaundice. He later underwent surgery after nutritional rehabilitation. This case report highlights the role of intrabiliary acetylcysteine infusions for mucous occlusions in IPMN.

Su1296 STEP WISE ANTEGRADE TREATMENT FOR HEPATICOJEJUNOSTOMY ANASTOMOTIC STRICTURE VIA EUS GUIDED HEPATICOGASTROSTOMY

Treatment of Hepaticojejunostomy (HJ) anastomotic stricture is always challenging. Current treatment such as enteroscopy-assisted ERCP is not always successful and might not be suitable for repeated endoscopic dilation. EUS guided hepaticogastrostomy (EUS HGS) is now an alternative biliary drainage method for benign biliary stricture but the treatment approach of this technique is still not well established. We retrospectively studied 7 patients with post-surgery HJ stricture who received EUS HGS approach after failed balloon-assisted enteroscopic drainage. In all cases, connection between left and right intrahepatic bile duct were confirmed by CT scan to ensure the maximal benefit of EUS HGS. Initial EUS HGS was performed using fully covered metallic stent (SEMS) 10x100 mm in 6 cases and 6x100 mm in one case. After tract maturation, SEMS were removed and anastomotic area was cannulated through the EUS HGS fistula. The anastomosis was dilated and multiple 7fr double pigtail plastic stents were placed from the jejunum to the stomach lumen across the stricture site (figure 1). The stents were exchanged every 2-4 months and lithotripsy was performed through HGS in case with intrahepatic duct stone following the treatment protocol (figure 2). The median age was 43 (32 -81). Overall 9 EUS HGS procedures were successfully performed in 7 patients. Stent migration occur in one patient who received 6x100 mm stent placement and in another patient who loss to follow up. In later cases, only 10x100 mm SEMS were used and SEMS were fixed to the stomach using hemoclips. During the subsequent procedure, cannulation across the stricture was performed using balloon occluded cholangiogram, rotatable sphincterotome or direct cholangioscope. HJ was successfully cannulated in the second procedure in 6 patients and we experienced one case of failed cannulation due to severe stricture and intrahepatic bile duct stone. No migration was seen after plastic stent placement. HJ stricture improved in cases that the HJ could be cannulated (6/7 patients) and all patients achieve complete biliary drainage. Complication included mild cholangitis after EUS HGS in all cases which was treated only by antibiotics. Median follow up time was 8.5 months (range 4-30 months). Antegrade treatment for HJ stricture via EUS HGS should be performed in step wise fashion. Migration after initial metallic stent placement is common so stent fixation and stent exchange to plastic stent should be followed after tract maturation.Flow chart demonstrate step wise treatment for hepaticojejunostomy strictureView Large Image Figure ViewerDownload Hi-res image Download (PPT)

V04-06 ENCRUSTATED METALLIC URETERAL STENT TREATED BY MINI NEPHROLITHOTOMY

INTRODUCTION AND OBJECTIVE: The use of polymeric double J stents for the management of ureteral strictures is effective for a short period of time, although they have limited use due to the risk of obstruction and to the need for periodic stent changes. Metal stents have been developed with the aim of maintaining greater ureteric patency, alleviating symptoms, and, especially, allowing less frequent exchanges. Although metallic stent changes are approved for 12 months, there are no concrete data defining a safe dwell-time to prevent clinically significant encrustations. Likewise, there are no reports of surgeries performed to treat metal stent encrustations. Our objective with this video is to describe a case of a large metallic ureteral stent encrustation successfully treated by Mini Percutaneous Nephrolithotomy (MiniPerc) in an obese patient. METHODS: A 48-year-old female was admitted at our hospital for treatment. The patient had previously undergone a metallic DJ stent implantation for the treatment of a chronic ureteral stricture but hasn’t had a stent exchange in the last 18 months due to loss of follow-up. Radiological exams revealed a large encrustation at the right renal pelvis (2,5x1,6cm). After the attempt of removing the stent by cystoscopy failed, a mini percutaneous nephrolithotomy was performed to treat the kidney stone and to implant another stent. RESULTS: After the procedure, the patient became stone-free and had a silicone DJ stent implanted. Metabolic evaluation of the urine did not reveal hypercalciuria or any other contributing factor for this severe complication. CONCLUSIONS: Large encrustations on a metallic ureteral stent are rare complications and may require surgical treatment. Mini percutaneous nephrolithotomy seems to provide a safe and feasible treatment option for these cases, even in obese patients. Source of Funding: Authors

Radiological retrograde ureteric stent exchange in women: a single-centre review

To evaluate the safety and efficacy of modified wire loop technique for retrograde stent exchange. All patients were from the KK Women and Children's Hospital where there is no on-site urology service. Patients were identified retrospectively from the institutional radiological information system (RIS) database. In total, 270 stents were removed and 238 replaced for 79 patients between January 2012 to December 2016. Success rates for stent removal and exchange as well as skin dose and fluoroscopy time were assessed. Stent exchange was successful in 234/238 (98%) of cases. Failure was due to loss of access (one case), inability to snare stent due to distorted anatomy (two cases), and extensive encrustation of stent (one case). In 252/270 (93%) cases, stent was removed using modified snare while in 18 (7%) cases, other snare devices were used. Average fluoroscopy time per stent for stent exchange was 573 seconds and average skin dose was 12,494 DAP/mGy•cm2. Fluoroscopy-guided retrograde ureteric stent exchange using the modified snare loop technique is effective, quick, and can be performed easily with equipment used in daily intervention practice. It may also be coupled with ureteroplasty, which may help the patient achieve eventual stent-free status.

Endoscopic nasal biliary drainage-guided approach after endoscopic ultrasound-guided hepaticojejunostomy: safe stent exchange technique.

Endoscopic nasal biliary drainage-guided approach after endoscopic ultrasound-guided hepaticojejunostomy: safe stent exchange technique.

Retrograde ureteric stent exchange in the female oncology patient by interventional radiology: the experience of a single tertiary referral centre.

Double-J stents are used to treat ureteric outflow obstruction. Deployed in antegrade or retrograde fashion, they relieve ureteric obstruction in several conditions including ureteric calculi, strictures and malignancy. Traditionally exchanged in an operating theatre (OT) under general anaesthetic (GA), more recently described is the technique of using fluoroscopic guidance under sedation. To assess the efficacy and safety of retrograde double-J stent exchange in an interventional radiology (IR) setting in a tertiary oncology referral centre over a 7-year period. Clinical data on 460 double-J stent exchanges in 126 female patients was acquired from the hospital electronic patient record. Four fellowship-trained interventional radiologists performed the procedures. A standard approach was used in conjunction with conscious sedation using midazolam and fentanyl. Use of the technique with certain anatomical variations is also described. Technical success rate was 96%. The main reasons for failure included failure to snare the stent (1.8%) and patient discomfort (1.1%). The overall complication rate was 5%: 5 category 1 (minor) and 18 category 3 outcomes, with the latter group requiring further intervention. Average screening time was 9.65min and the average radiation dose was 2018.24mGy/m2. We also demonstrate the successful use of this method in patients with unusual anatomy and ileal conduits. Fluoroscopic-guided retrograde double-J stent exchange is a safe and effective procedure that can be performed with a high degree of success using equipment and techniques used in daily IR practice. This approach precludes the need for GA, reduces OT utilisation and is well tolerated in a patient group for whom this procedure is typically palliative.

Successful Endoscopic Management of Obstructive Jaundice in Von Hippel-Lindau Disease Caused by Multiple Pancreatic Serous Cystadenomas Extrinsic Compression - A Case Report

Serous cystadenomas of the pancreas are a common entity in patients with von Hippel-Lindau (vHL) disease. However, to date, only thirteen cases of pancreatic cystic lesions causing obstructive jaundice in vHL patients have been reported in the literature, and these were the result of distal CBD stricture. In this study, we present a rare first case report of multiple large pancreatic serous cystadenomas causing obstructive jaundice via extrinsic compression of the mid CBD in a 27-year-old female with vHL. Biliary decompression has been successfully achieved with ERCP and stent placement, with serial stent exchanges every 2 months. Given the patient’s young age and the morbidity associated with total pancreatectomy, we have elected to pursue a more conservative approach to her biliary obstruction via serial stent exchanges until they are no longer successful at achieving decompression, at which point we will proceed with surgical intervention such as biliary bypass or total pancreatectomy.

Endoscopic Necrosectomy of Walled-Off Necrosis following Severe Pancreatitis Using a Hot AxiosTM Stent – A Case Series

Background: Walled-off necrosis is a common complication of severe pancreatitis. Guidelines recommend endoscopic transgastric necrosectomy as therapy of choice. Different endoscopic approaches are possible. Methods: We retrospectively analyzed our series of 9 patients where necrosectomy was performed after application of a lumen-apposing metal stent (LAMS) delivered using a Hot Axios^TM Stent device. Results: In all 9 cases, the walled-off necrosis resolved completely. Necrosectomy was performed through the LAMS (mean: 5.7 times). Endoscopic necrosectomy was repeated every 3rd–7th day using 10- or 15-mm snares. There were no major complications. Especially, no early or delayed bleeding was seen. Conclusion: The Hot Axios^TM Stent device is a safe method for necrosectomy of walled-off necrosis. It enables puncture, drainage, and LAMS insertion in a single delivery, followed by several courses of necrosectomy if needed without stent exchange.