Stent Replacement Research Articles

The "straighten pigtail" technique for selective replacement of a pigtail plastic stent.

The "straighten pigtail" technique for selective replacement of a pigtail plastic stent.

Efficacy and safety of endoscopic stent placement for afferent loop obstruction using a short double-balloon endoscopy.

BackgroundAfferent loop obstruction (ALO) is a rare mechanical complication that occurs after gastrojejunostomy. Recently the use of double‐balloon endoscopy (DBE) can be useful for benign and malignant ALO.MethodsWe retrospectively identified 22 patients who underwent DBE for ALO from January 2009 to December 2020. We evaluated the efficacy and safety of short DBE treatment for ALO.ResultsShort DBE was able to reach an obstructive site in the afferent limb in all patients (100%) and was able to reach the blind end in 14 patients (64%). The technical success rate was 100%, and the clinical success rate was 95%. Procedure‐related adverse events occurred in two patients (9%). In the case of benign ALO, three of nine patients showed improvement in ALO with single stent placement. Two of nine patients improved after the replacement of the plastic stent (PS) two or three times. Four of nine patients continued with the replacement of PS. In the case of malignant ALO, the metallic stent was placed in 10 patients, and eight patients with metallic stents did not experience stent occlusion until they died. Reintervention was attempted in six patients (27%) with benign ALO but was not attempted in malignant ALO.ConclusionsTreatments for ALO using the short DBE was effective and relatively safe because the technical and clinical success rates were very high and there were relatively low complications. Consequently, short DBE could be the first‐choice treatment for both benign and malignant ALO.

Uretero-Iliac Artery Fistula

Uretero-Iliac Artery Fistula: a rare cause of haematuria A 90-year-old male presented to our hospital with a onemonth history of intermittent gross hematuria. He had stage II rectal cancer and received neo-adjuvant concurrent chemoradiotherapy and low anterior resection 5 years ago. Additionally, he was under regular bilateral ureteral catheter replacement due to radiation related ureteral stricture for two years.\r\nDuring examination, there was no abdominal tenderness or flank pain. Urine analysis showed pyuria and hematuria. Abdominal and pelvic computed tomography without contrast medium revealed only bilateralwithout contrast medium revealed only bilateral hydronephrosis. After admission, several hematuria episodes that required blood transfusions and bladder irrigation occurred at an interval of 3 days and resolved spontaneously. Cystoscopy was unmarkable except bleeding from right ureteral orifice during ureteral stent replacement. Concerns for a ureteral arterial fistula prompted an angiogram, which later on proved the existence of a fistula with pseudoaneurysm(Figure 1) between external iliac and distal right ureter(Figure 1). A stent graft was placed from the common iliac into the right external iliac artery. After stent-graft deployment, the aneurysm is no longer opacified. At the 2-month follow-up, no hematuria recurrence was detected.\r\n

Retrograde stent with external string for pediatric robotic pyeloplasty: does it reduce cost and complications?

Robotic-assisted pyeloplasty (RAP) is a mainstay in the treatment of ureteropelvic junction obstruction (UPJO) in children. At our institution, to limit planned operating rooms visits we have placed a ureteral stent with an external string (SWES) immediately prior to RAP. In this study, we sought to quantify the operative time, complications, and costs associated with this approach compared to the traditional approach, requiring subsequent stent removal in the operating room. We hypothesized the SWES cohort would have decreased cost, yet with similar operative time and complications. We retrospectively collected all RAPs performed at our institution using the SWES approach (Aug 2012-July 2017). We excluded those with a redo pyeloplasty, and/or a percutaneous nephrostomy tube for post-operative drainage. We collected 30-day costs linked to the patients' MRN using the Pediatric Health Information System (PHIS) database. We compared 30-day healthare costs for all patients following RAP. We compared our SWES group to a national cohort of all pediatric RAP during the same time period. Lastly, we sent an anonymous, electronic survey to urologists of all PHIS institutions to identify the predominant postoperative drainage, nationally. Within our institution, we reviewed all those treated with SWES (n = 85) (Table 1). The median 30-day cost was $10,548 among those with SWES (Table 2). This was significantly less than the overall, national cohort of all pediatric RAP during the same period ($14,119, p < 0.001). There was a 15.5 % rate of unplanned return to the hospital in the SWES group. Of those unplanned returns, 8.2 % (7/85) had unplanned return for a procedure (3 for unplanned stent removal, 2 for nephrostomy tube for persistent obstruction, 1 for omental hernia, and 1 for stent replacement). With a 42.5 % (37/87) response rate, our nationwide survey found 84.6 % primarily leave stents WITHOUT a string, 7.7 % left nephrostomy tubes, and 7.7 % stents with strings. During pediatric RAP, placement of a SWES takes little time, carries a risk of unplanned visit to the operating room, saves the patient a certain, second anesthetic for stent removal, and amounts to a cost savings of approximately 25 %.

Management and outcomes of hydronephrosis in patients with metastatic extramammary Paget's disease: A retrospective analysis.

Hydronephrosis in extramammary Paget's disease (EMPD) with distant metastasis (metastatic EMPD) has been observed in medical practice; however, its prognosis remains unclear. Retrospective analyses were performed to assess the management and outcomes of hydronephrosis in metastatic EMPD. During a follow-up of 44 patients with metastatic EMPD, 13 (30%) developed hydronephrosis. Ten (77%) of the 13 patients with hydronephrosis had impaired renal function (estimated glomerular filtration rate: <60 ml/min/1.73m2 ), and ureteral stents were placed in every patient with impaired renal function. The stent was placed successfully in all 10 patients, and their renal function recovered within a median period of 7 days. Importantly, each of these patients continued chemotherapy, and none of them experienced stent failure. The median overall survival time (OS) in patients with metastatic EMPD and hydronephrosis (n=13) was 7.8 months. Treatment for hydronephrosis was not a significant factor for OS, and median OS in patients who underwent ureteral stent replacement (n=10) was 14.7 months. Collectively, our results indicate that hydronephrosis is relatively common, and ureteral stent placement should be considered in cases of metastatic EMPD with hydronephrosis to maintain renal function and continue chemotherapy toward a better prognosis.

НЕТРАВМАТИЧЕСКИЙ РАЗРЫВ ФОРНИКСА С ЭКСТРАВАЗАЦИЕЙ КОНТРАСТА

Purpose: Description of a clinical case of surgical treatment of nontraumatic rupture of the renal calyx fornix, with extravasation of contrast agent into the perirenal tissue. Material and methods: Provided surgical treatment to a patient with spontaneous rupture of the calyx fornix on the background of ureteral obstruction caused by a stone. Results: Considering the concomitant pathology in the form of obstructive pyelonephritis, it was decided to drain the upper urinary tract with an external stent. After 7 days, the patient underwent replacement of the external stent with the internal one. The patient underwent antibacterial, anti-inflammatory therapy, with a positive clinical, laboratory effect. Retrograde pyelography was performed 7 days later. Violations of the integrity of the cavity system of the left kidney were not revealed. The external stent was replaced with an internal one. After 2 months, ureterolitho-extraction was performed on the left. Conclusion: From the data of the world literature and our own experience, we can conclude that spontaneous, non-traumatic rupture of the fornix is an extremely rare, urgent urological disease. We assume that the development of this process is similar to the Burhave syndrome, since smooth muscle fibers are present in the esophagus as well as in the esophagus. In order to provide immediate assistance to such patients, it is necessary to urgently drain the upper urinary tract. Timely diagnosis of this condition requires rapid tactics in the form of immediate ultrasound, radiological diagnostic methods, as well as computed tomography. The operational manual on the removal of stones in this case should be postponed for 2–3 weeks.

Fabrication and evaluation of bioresorbable scaffolds for interventional cardiology application with sufficient drug release.

Objective(s):Bioresorbable scaffolds have been advocated as the new generation in interventional cardiology because they could provide temporary scaffolds and then disappear with resorption. Although, the available stents in clinical trials exhibited biosafety, efficacy, no death, and no apparent thrombosis, Mg-substrate degradation on drug release has not been investigated.Materials and Methods:Therefore, more research has been needed to legitimize the replacement of current stents with Mg-based stents. UV-Vis spectrophotometer, scanning electron microscope (SEM), X-ray diffraction (XRD), pH measurement, H₂ evolution, and corrosion tests determined the change in hybrid properties and drug release rate. Results:The effect of Mg degradation on drug release from poly-L-lactide (PLLA) specimen was much higher than that of the L605/PLLA sample. Hydrogen evolution caused by magnesium degradation compelled everolimus out without significant PLLA decomposition during the first 100 days, while formation of Mg(OH)2 caused the PLLA to deform and crack. Conclusion:A combined mechanism of lattice/hole diffusion-dissolution governed the release of everolimus with the activation energies of 5.409 kJ/mol and 4.936 kJ/mol for the first 24 hr and diffusion coefficients 6.06×10-10 and 3.64×10-11cm2/s for the 50th to 100th days. Prolonged suppression of hyperplasia within the smooth muscle cells by hybrid stent insertion could bring about the cessation of restenosis.

Endoscopic Treatment for Pediatric Esophageal Stenosis Induced by Chemical Burn, Congenitally, or After Surgical Repair of Esophageal Atresia

ObjectivesTo evaluate the safety and efficacy of endoscopic treatment for congenital pediatric esophageal stenosis or pediatric stenosis that develops after a chemical burn or surgical repair of esophageal atresia.MethodsWe retrospectively reviewed the medical records of 15 pediatric patients who underwent endoscopic treatments (dilation and/or stenting and/or incision) for congenital esophageal stenosis or esophageal stenosis that developed after a chemical burn or surgical repair of esophageal atresia, between January 2010 and January 2019. The patients were periodically followed-up to assess the safety and efficacy of treatment by comparing the diameter of stricture and dysphagia score before and after procedures, and complications or recurrence.ResultsAll children successfully underwent the procedures. Fourteen of the 15 patients received endoscopic balloon dilation (EBD) as the first step of treatment, but EBD alone only resolved the symptoms in two patients. The remaining patients received other comprehensive treatments, such as EBD with endoscopic incision (EI), EBD with stent replacement, or a combination of EBD, stent replacement, and EI. Eleven (11/15, 73.3%) patients experienced symptomatic relief after endoscopic treatment, and recurrence was noted in four patients on 3–36 months after the final endoscopic treatment. All four patients underwent esophageal surgery to relieve their symptoms. Until October 2021, all patients experienced symptom relief, and their dysphagia scores decreased from 3–4 to 0–1 during the follow-up period of 8–121 months. The average diameter of stenosis was increased from 0.34 cm (range 0.2–0.7 cm) to 1.03 cm (range 0.8–1.2 cm). No severe complications occurred during endoscopic treatment and follow-up.ConclusionsEndoscopic treatment is safe and effective for pediatric esophageal stenosis that is congenital or induced by chemical burns or surgical repair of esophageal atresia. Comparative large-scale studies are required to confirm our findings.

Real-life patency of plastic biliary stents in the pandemic era: is stent removal after 6 months safe and effective?

Background The SARS-CoV-2 pandemic conditioned the optimal timing of some endoscopic procedures. ESGE guidelines recommend replacement or removal of the plastic biliary stents within 3–6 months to reduce the risk of complications. Our aim was to analyse the outcomes of patients who had delayed plastic biliary stent removal following endoscopic retrograde cholangiopancreatography (ERCP) in the pandemic era. Methods Retrospective study including consecutive ERCPs with plastic biliary stent placement between January 2019 and December 2021. Delayed removal was defined as presence of biliary stent >6 months after ERCP. The evaluated outcomes were stent migration, stent dysfunction, obstructive jaundice, cholangitis, acute pancreatitis, hospitalization, and biliary pathology-related mortality. Results One-hundred and twenty ERCPs were included, 56.7% male patients, with a mean age of 69.4 ± 15.7 years. Indications for plastic biliary stent insertion were choledocholithiasis (72.5%), benign biliary stricture (20.0%), and post-cholecystectomy fistula (7.5%). Delayed stent removal occurred in 32.5% of the cases. The median time to stent removal was 3.5 ± 1.3 months for early removal and 8.6 ± 3.1 months for delayed removal. Patients who had delayed stent removal did not have a significantly higher frequency of stent migration (20.5 vs 11.1%, p = 0.17), stent dysfunction (17.9 vs 13.6%, p = 0.53), hospitalization (17.9 vs 14.8%, p = 0.66), obstructive jaundice (2.6 vs 0.0%, p = 0.33), cholangitis (10.3 vs 13.6%, p = 0.77), acute pancreatitis (0.0 vs 1.2%, p = 1.0), or biliary pathology-related mortality (2.6 vs 1.2%, p = 0.55). Conclusions Delayed plastic biliary stent removal does not seem to have a negative impact on patients’ outcomes. In the current pandemic situation, while scheduled endoscopic procedures may have to be postponed, elective removal of plastic biliary stents can be safely deferred.

Subtotal Stomach Preserving Pancreaticoduodenectomy for a 14-Year-Old Boy with Benign Duodenal Stenosis

Background: Subtotal stomach preserving pancreaticoduodenectomy (SSpPD) is one of the highly invasive surgery and rarely performed on pediatric patients. We show a pediatric patient who underwent SSpPD because of benign duodenal stenosis and Groove pancreatitis associated with duodenal ulcer. Case: A 14-year-old boy had been suffered from repeated abdominal pain of unknown cause for 5 years. Because of abdominal pain and vomiting, he was referred to our hospital, and diagnosed with duodenal stenosis and Groove pancreatitis. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated a biliary-duodenal fistula and the main pancreatic duct stenosis in the pancreas head. Although endoscopic pancreatic stenting was performed into the narrowed pancreatic duct, the replacement of stent became difficult due to the exacerbation of duodenal stenosis, and the patient was introduced to our department for surgery. Treatment course: SSpPD was performed. Operation time was 6 hours 49 minutes, and the amount of blood loss was 10 ml. He could take a solid diet postoperatively, and was discharged without any complication 18 days after the surgery. Discussion: There are several reports of pancreaticoduodenectomy in children for malignant tumors, but reports of benign diseases such as this case are extremely rare. Considering the requirement of long-term prognosis and quality of life, the operative indication of SSpPD for pediatric patient with benign diseases should be carefully decided.

Isolated superior mesenteric artery dissection managed with stent replacement and diagnostic laparoscopy: A case study

Isolated superior mesenteric artery dissection managed with stent replacement and diagnostic laparoscopy: A case study

Female-only Ureteral Stent Placement and Replacement Technique Using Pig-tail Straightener

Female-only Ureteral Stent Placement and Replacement Technique Using Pig-tail Straightener

Comparison of Postoperative Outcomes of Sutureless versus Stented Bioprosthetic Aortic Valve Replacement.

ObjectiveSutureless aortic valve replacement (Su-AVR) offers an alternative to supra-annular stented biological aortic prostheses. This single-center study aimed to compare early outcomes after aortic valve replacement with sutureless and conventional stented bioprostheses. MethodsIn this retrospective study, we analyzed 52 patients who underwent aortic valve replacement with sutureless and stented bioprostheses between January 2013 and October 2017. Sorin Perceval S sutureless valves were implanted in group 1 and Sorin Mitroflow stented bioprosthetic valves were used in group 2. Postoperative outcomes, including demographics, cardiopulmonary bypass (CPB) times, cross-clamp times, morbidity and mortality, as well as echocardiography in the first month, were compared.ResultsMortality occurred in 1 (3.6%) patient in group 1, and in 2 (8.3%) patients in group 2 (P=0.186). Group 1 had significantly shorter CPB (61.6±26.1 min vs. 106.3±32.7 min, P=0.001) and cross-clamp (30.9±13.6 min vs. 73.3±17.3 min, P=0.001) times. The length of stay in the intensive care unit (1.9±1.3 days vs. 2.4±4.9 days, P=0.598) and hospital stay (7.6±2.7 days vs. 7.3±2.6 days, P=0.66) were similar. Postoperatively, there was no statistically significant difference between the two groups in echocardiography results, and morbidities. The mean aortic valve gradient was 13.5±5.8 mmHg in group 1 and 14.5±8.0 mmHg in group 2 (P=0.634). Paravalvular regurgitation was diagnosed in 3 (10.7%) patients in group 1 and in 1 (4.2%) patient in group 2 (P=0.220). ConclusionsSu-AVR resulted in shorter cross-clamp and CPB times. However, early mortality, postoperative morbidity, and echocardiography results were similar between groups.

Efficiency of hybrid surgical treatment of the aortic arch and descending thoracic aorta aneurysm

OBJECTIVE. Assessment of the mid-term results after various types of debranching in hybrid surgery of the aortic arch and descending thoracic aorta.METHODS AND MATERIALS. 47 patients with various pathologies of the aortic arch and descending thoracic aorta were operated on. Six of them suffered from type IIIa dissection and 26 from type IIIb dissection according to DeBakey classification, 15 patients had true aortic aneurysms. The following interventions were performed: total aortic arch debranching (n=5), cross subclavian-subclavian-left-common carotid (n=14) or cross carotid-carotid-subclavian bypass (n=7); subclavian-carotid transposition or bypass (n=12); Chimney technique for the aortic arch aneurysm (n=8); in situ fenestration of the endoprosthesis (n=1). Elective surgery was performed in 32 patients, emergency in 15.RESULTS. Technical success achieved in 100 %. The overall hospital mortality rate was 10.6 % (n=5), elective surgery mortality rate was 9.3 % (n=3), in emergency cases - 13.3 % (n=2). Causes of mortality: stroke (n=1), multiple organ failure after prosthetic ascending aorta due to retrograde dissection after stent graft implantation (n=1), pneumonia (n=1), acute myocardial infarction (n=1), profuse bleeding (n=1). Cumulative survival rate was 87.5 % over 5 years, freedom from reinterventions - 89.1 %. During the first year of observation, 3 patients underwent stent graft replacement of the descending thoracic aorta due to formation of a dissection below the primary stent graft (n=1), open prosthesis of the ascending aorta due to it retrograde dissection (n=1), endofixation of the stent graft with embolization of the false lumen (n=1).CONCLUSION. Hybrid surgery on the aortic arch and the descending thoracic aorta is safe and effective treatment. Regular follow-up and timely treatment of complications in the long term after hybrid or endovascular interventions are necessary to improve long-term results.

Clinical characteristics, aetiology and mortality/recurrence risk factors of acute cholangitis in patients with and without biliary stent

ObjectivesAcute cholangitis is one of the most frequent complications in patients carrying biliary stents. The aim of our study is to analyze the demographic and clinical characteristics, as well as the microbiological profile and evolution of patients with acute bacteremic cholangitis, comparing them based upon they were or not biliary stent carriers. MethodsWe performed a retrospective analysis of all consecutive patients over 18 years-old with a stent placement in our center between 2008 and 2017 were included. We compared them with our prospective cohort of patients with a diagnosis of acute bacteremic cholangitis. Primary outcome was 30-day mortality. Secondary outcome was clinical cure at day 7, 14-day mortality and 90-day recurrence. ResultsTwo hundred and seventy-three patients were analyzed, including 156 in the stent-related (SR) and 117 in the stent not-related (SNR) group, respectively. Stent-related colangitis patients were younger, with more comorbidities and with a greater severity of infection. Escherichia coli and Klebsiella pneumonia were the most frequent isolation. Enterococcus spp. was the third most frequent isolation in SR group but were uncommon in SNR patients; where E. coli was the most prevalent microorganism. Septic shock (HR 3.44, 95% [CI 1.18–8.77]), inadequate empirical treatment (HR 2.65, 95% CI [1.38–.7.98]) and advanced neoplasia (HR 2.41, 95% CI [1.55–6.44]) were independent 30-day mortality risk factors. The 90-day recurrence rate significantly higher in those patients with stent-related cholangitis (29% vs. 13%, p=0.016) and stent replacement was associated with lower recurrence rate (HR 0.38, 95% CI [0.11–0.77]). ConclusionsClinical and microbiological profile, as well as outcome of patients with SR and SNR cholangitis were different. In SR group, recurrence rate was high and stent replacement was associated with a lower risk.

Performance of plastic stents used for benign and malignant biliary strictures: experience of a single high‑volume endoscopy unit.

Endoscopic plastic biliary stenting has been used for more than 30 years as a temporary or definitive treatment of benign and malignant neoplasms. These stents are commonly available, inexpensive, and easy to implant. We aimed to evaluate the duration of plastic stent patency, to assess complications associated with stent use, and to determine the optimal timing of stent replacement depending on the indication for biliary stenting. This was a retrospective cohort study with a 5‑year follow‑up including patients who underwent plastic biliary stent implantation between 2012 and 2013 in a tertiary referral gastroenterological center. The performance of stents was assessed on the basis of medical records, direct contact with patients or their family members, and information derived from the national death registry. We assessed 830 biliary stenting procedures performed in 346 patients. The indications for biliary stenting included choledocholithiasis in 120 patients (34.7%), benign stricture in 70 patients (20.2%), and malignant stricture in 156 patients (45.1%). The mean duration of stent patency for these conditions was 110, 106, and 55 days, respectively (P <0.001). Stents implanted for malignant perihilar strictures had a shorter duration of patency than those used for distal strictures (40 days vs 76 days, P = 0.002). The patency of plastic stents depends on the underlying disease. In patients with benign biliary disease, stent replacement is recommended after about 3.5 months. In patients with cancer, the timing of stent replacement should be guided by survival prognosis and location of stricture.

CHEST IN CRISIS: A CASE OF BRONCHOBILIARY FISTULA

TOPIC: Signs and Symptoms of Chest Diseases TYPE: Medical Student/Resident Case Reports INTRODUCTION: Bronchobiliary fistula (BBF) is a rare occurrence of altered anatomy of the biliary duct system in which it connects to the lungs. Biliptysis is pathognomonic for this condition. Predisposing factors include malignancy, bile duct obstruction, trauma, and surgery. Our case highlights a patient who presented with several months of non-resolving right middle lobe (RML) pneumonia who was later found to have a BBF. CASE PRESENTATION: Our patient is a 43-year-old male with a history of colon cancer with liver metastasis on palliative chemotherapy who presented after multiple episodes of RML pneumonia. He had endoscopic retrograde cholangiopancreatography (ERCP) with stent placement for malignant biliary obstruction. Three months later, he had fever, cough, and scant yellow sputum with chest x-ray (CXR) findings of RML consolidation. He received appropriate antibiotics for community-acquired pneumonia. His symptoms recurred two weeks later. During that admission, the CT chest showed consolidation of the RML. Sputum culture grew Klebsiella pneumoniae and was treated appropriately. He had two more similar episodes. Bronchoscopy showed erythematous endobronchial mucosa in the RML with carbapenem-resistant Enterobacteriaceae (CRE) and Klebsiella pneumoniae on culture. Transbronchial lung biopsy was negative for malignancy. After seven months from the initial ERCP, he presented with copious bilious sputum and right pleuritic chest pain. Repeat CT chest showed persistent RML consolidation and 4 cm fluid collection along the hepatic capsule which grew CRE and Klebsiella pneumoniae. This raised suspicion for bronchobiliary fistula. A hepatobiliary iminodiacetic acid (HIDA) scan done did not demonstrate the presence of a fistula. Magnetic resonance cholangiography (MRC) was done which showed a small sinus tract that represented a BBF. He underwent right anterior sectionectomy of the liver with diaphragm repair and ERCP with replacement of biliary stent. DISCUSSION: The most common cause of acquired BBF is liver malignancy likely through obstruction which produces inflammation in the subdiaphragmatic space with subsequent rupture into the bronchial system. Patients can present with pneumonia, while it is rare, it is the most common comorbidity associated with BBF. Our patient presented with biliptysis and recurrent pneumonia with multidrug-resistant organisms. MRC and HIDA are preferred studies as they are non-invasive. Our patient's HIDA scan was not diagnostic but the MRC showed the BBF. Our patient underwent segmental hepatectomy and ERCP with stent replacement with subsequent symptom resolution. CONCLUSIONS: A high index of suspicion is required to diagnose BBF when the presentation is atypical such as in the case of recurrent RML pneumonia. Early diagnosis is important to prevent progressive antibiotic resistance. Non-invasive modalities like HIDA and MRC are preferred for making the diagnosis. REFERENCE #1: Liao G-Q. Management of acquired bronchobiliary fistula: A systematic literature review of 68 cases published in 30 years. World J Gastroenterol. 2011;17(33):3842. doi:10.3748/wjg.v17.i33.3842 REFERENCE #2: Aduna M, Larena JA, Martín D, Martínez-Guereñu B, Aguirre I, Astigarraga E. Bile duct leaks after laparoscopic cholecystectomy: value of contrast-enhanced MRCP. Abdom Imaging. 2005;30(4):480-487. doi:10.1007/s00261-004-0276-2 DISCLOSURES: No relevant relationships by Tundun babalola, source=Web Response No relevant relationships by Afoma King, source=Web Response No relevant relationships by Nirvi Shah, source=Web Response No relevant relationships by susan waitimu, source=Web Response

LET'S MEET IN THE MIDDLE: SIMULTANEOUS ENDOSCOPIC AND BRONCHOSCOPIC SUTURE REPAIR TO CLOSE A LEFT MAIN-STEM MALIGNANT BRONCHO-ESOPHAGEAL FISTULA

TOPIC: Procedures TYPE: Fellow Case Reports INTRODUCTION: This case highlights a unique approach to manage broncho-esophageal fistula which is refractory to esophageal stenting. CASE PRESENTATION: We describe the case of a 68 year old female with stage IV squamous cell carcinoma of the esophagus status post chemotherapy, immunotherapy and radiation complicated by esophageal stricture requiring a fully covered 18mmx12.3cm WallFlex stent. Approximately three months after stent placement, she developed coughing with oral intake. Swallow study revealed contrast refluxing into the trachea, and CT scan showed presence of left mainstem broncho-esophageal fistula. Bronchoscopy demonstrated thick purulent secretions and a 1-1.5 cm defect of the left main, 5mm distal to the main carina. The esophageal stent was visualized through the defect. She underwent EGD with removal of the stent and was also found to have a large 3cm deep defect in the proximal esophagus and ulceration throughout the mid-esophagus. Due to high risk of perforation, the esophagus was not stable enough to safely allow stent replacement. Her defect was deemed non-operable. Bronchial stenting was considered; however, there was increased risk of pressure necrosis and mediastinits plus proximity of the fistula to the main carina made stenting difficult to size. We opted to pursue simultaneous flexible endoscopy with rigid bronchoscopy to close her broncho-esophageal fistula. We utilized an X-Tack Endoscopic HeliX Tacking System with one running suture as well as placed two 2.0 36 inch braided non-absorbable pledgeted sutures from the esophageal side with closure on the bronchial side with a Cor-Knot device. There was no evidence of saline leak over the fistula. Post-closure, she tolerated bedside swallow and was able to drink liquid without coughing. Follow up esophagram is pending. DISCUSSION: The current standard of care for management of malignant tracheal-esophageal fistula is esophageal with/without broncho-tracheal stent and is palliative in intent. Stenting was not a safe option in our patient. The use sutures placed via rigid scopes from the esophageal side to tracheal side with closure with a Cor-Knot device for management of tracheo-esophageal fistula has been described in one prior case report.(1) Our case further demonstrates the feasibility of this technique for management of airway-esophageal fistula. Our case is unique as it treats a fistula in the left mainstem bronchus as opposed to the trachea. Due to the distal location of the defect, we were unable to use the rigid esophageal tube to pass the sutures, so we straightened the sutures and successfully passed them through a flexible EGD scope. Our case also used an X-Tack running suture device to further stabilize our closure. CONCLUSIONS: This case demonstrates an effective alternative approach and potentially more viable solution to treat broncho-esophageal fistulas when endoscopic/endobronchial stenting is not permissible. REFERENCE #1: Mozer AB, Michel E, Gillespie C, Bharat A. Bronchoendoscopic Repair of Tracheoesophageal Fistula. Am J Respir Crit Care Med. 2019 Sep 15;200(6):774-775. doi: 10.1164/rccm.201812-2255IM. PMID: 30973758; PMCID: PMC6775884. DISCLOSURES: No relevant relationships by Navtej Buttar, source=Web Response No relevant relationships by Sangita Goel, source=Web Response No relevant relationships by Ryan Kern, source=Web Response No relevant relationships by John Mullon, source=Web Response No relevant relationships by Darlene Nelson, source=Web Response Research grant relationship with Intuitive Surgical Please note: $5001 - $20000 by Janani Reisenauer, source=Web Response, value=Grant/Research Support No relevant relationships by Linh Vu, source=Web Response

S3460 A Case of Forgotten Biliary Stent Presenting as Multiple Liver Lesions: A Single Institution Experience

Introduction: Placement of a biliary stent is essential in certain biliary pathologies for prevention of cholangitis. The major disadvantage of biliary stenting is clogging of the endoprosthesis. We present a case of hepatic abscesses in a non-compliant patient with history of biliary stents. Case Description/Methods: 37 year old white female with no past medical history was admitted for abdominal pain since past four days. Patient complained of right upper quadrant pain, radiating to the back associated with fever, fatigue, loss of appetite and diarrhea. Review of system was negative for weight loss, travel, drug use. Surgical history was significant for cholecystectomy with intraoperative cholangiography for choledocholithiasis followed by stent placement ten years ago. Family and social history were insignificant. Patient had right upper quadrant tenderness on palpation but rest of the physical exam was not significant. Laboratory findings were significant for leukocytosis with left shift. On CT imaging multiple hypodense masses in the dome of the liver with intrahepatic biliary ductal dilatation and two biliary stents. On endoscopic retrograde cholangiopancreatography the common bile duct appeared dilated with radiolucent filling of innumerable scattered lesions liver. Old stents were removed followed by drainage of pus, stone extractions and new stent placement with successful drainage of bile. Patient recovered well after the procedure and was discharged on antibiotics. On follow up imaging study, previously seen multiple hepatic lesions were not noted. The follow up cholangiopancreatography, previously noted innumerable hepatic lesions had resolved Discussion: Biliary stent placement is important in maintaining bile flow in cases of choledocholithiasis with cholangitis. Replacement of plastic stents is therefore recommended every 3-6 months to prevent stent related complications. Long-standing biliary stents increase the risk of cholangitis due to formation of biliary stones, as the biliary stent itself may serve as a nidus for stone formation. The rate of complications, such as cholangitis or stent impaction, might be increased as the stent was in place for a longer duration, and CBD stone development ultimately occurred in most cases of long-standing biliary stent. All patients should be informed of the possibility of complications related to retained long-term endoprosthesis placement, and stent change or definite treatment should be considered within 1 year of stent placement.Figure 1.: PRE and POST Imaging after stent removal.

How to Build OP-MEG: Specific Issues and Challenges

Symptomatic innominate artery stenosis presenting as hemodynamic bilateral cerebral ischemia is uncommon. We present a rare case of the severe stenosis of the origin of an innominate artery and severe stenosis of bilateral internal carotid artery that induced hemodynamic cerebral ischemia after ipsilateral axillary artery-bilateral femoral artery bypass and was treated with stent replacement of the innominate artery and right internal carotid artery.A 64-year-old woman who previously had undergone right axillary artery-bilateral femoral artery anastomosis for abdominal aorta high obstruction had been suffering from chronic dizziness and so visited our department. Findings of the examination included the severe stenosis of the origin of an innominate artery and severe stenosis of bilateral internal carotid artery, causing hemodynamic cerebral ischemia. She underwent stent replacement of the innominate artery and right carotid artery stenting via a right transbrachial approach. Her symptoms were relieved postoperatively.For the sake of improving the hemodynamic cerebral ischemia, we performed stent replacement for innominate artery stenosis and right carotid artery stenting. Endovascular treatment of subclavian and innominate artery disease is a safe procedure. In addition, for the protection of thromboembolic migration, we performed balloon protection of the external carotid artery and filter protection of the internal carotid artery.Stent replacement for these lesions can be performed safely with the right approach and protection methods, even when the only accessible route is the right brachial artery.