Stent Usage Research Articles

Importance of the gynecologic oncologist in management of cesarean hysterectomy for Placenta Accreta Spectrum (PAS)

ObjectivePlacenta Accreta Spectrum (PAS) is an invasive placental disorder characterized by significant maternal and fetal morbidity. Utilization of multidisciplinary teams has been shown to optimize patient outcomes. Our objective was to assess the impact of cesarean hysterectomy performed by gynecologic oncologists versus Ob/Gyn specialists in maternal morbidity. MethodsA retrospective cohort study was performed of singleton, non-anomalous pregnancies complicated by PAS University of Texas Health San Antonio Placenta Accreta program from 2010 to 2021. Our primary outcome was a maternal morbidity composite of any of the following: estimated blood loss >2 L, ICU admission, intraoperative acidosis and post-operative length of stay >4 days. In addition, demographic and pregnancy data were obtained. Univariate and multivariate analyses were performed to identify the individual impact of variables such as general anesthesia, episodes of vaginal bleeding, uterine artery embolization, emergent delivery and placenta percreta pathology. Results122 pregnancies complicated by PAS who underwent cesarean hysterectomy were identified from 2010 to 2021. Gynecologic oncologists were the primary surgeons for 62 (50.8%) of these cases. The involvement of gynecologic oncologists increased over the time period from 16% to 80%. Gynecologic oncologists were more like to be involved in cases with an antenatal diagnosis of placenta percreta (11.7 vs 37.1%, p = 0.001) and these cases were characterized by increased composite maternal morbidity (65 vs 83.9%, p = 0.02). These cases were also significantly longer (151 vs 271 min, p < 0.0001), involved greater usage of urinary stents (36.7 vs 66.1%, p = 0.002) and had longer post-operative lengths of stay (3 vs 4 days, p < 0.0001). PAS cesarean hysterectomies by gynecologic oncologists were less likely to be supracervical (25 vs 3.2%, p = 0.0005). Multivariate analysis controlling for placenta percreta, uterine artery embolization, vaginal bleeding and emergent delivery showed no difference in composite maternal morbidity (aOR = 0.95, 95%CI [0.35–2.52]) and lower rates of intraoperative acidosis (aOR = 0.36, 95%CI [0.14–0.93]) or post-operative length of stay >4 days (aOR = 0.37, 95%CI [0.15–0.91]). ConclusionsGynecologic oncologists play a critical role in the surgical management of PAS cesarean hysterectomies. When compared to Ob/Gyn specialists, gynecologic oncologists are more likely to act as primary surgeons in complex cases similar morbidity and greater post-operative outcomes.

Feasibility and Results of the Stentectomy Procedure Performed as Rescue Treatment for Acute Thrombosis of Self-Expandable Intracranial Stents: A Case Series.

Self-expandable stents have been increasingly used for endovascular treatment of intracranial aneurysms. Because the usage of intracranial stents has increased overall, total numbers of complications associated with these devices have increased. Thrombosis, distortion, or incomplete opening of stents are potential complications that may result in occlusion of the parent artery. In such cases, removal of the stent (stentectomy) may be the only solution to avoid serious clinical consequences. To investigate the feasibility and efficacy of a novel stentectomy technique for removal of thrombosed self-expandable stents. A retrospective review was performed of patients who underwent the stentectomy procedure. Initial and follow-up imaging and clinical outcomes were assessed. Immediate postprocedural and follow-up clinical statuses were assessed using the modified Rankin scale. Seven patients were included in this study (mean age: 54.1 years). The stentectomy was successful in 6 of 7 patients (85.7%). Seven stents in 6 patients were successfully removed to treat the acute in-stent thrombosis that was resistant to alternative bail-out treatments. The removed stents were self-expandable braided in 2 patients, flow diverters in 2 patients, and laser cut open-cell stents in 2 patients. Stentectomy failed to retrieve a thrombosed braided stent in 1 patient. The modified Rankin scale score of all patients who underwent a success stentectomy was ≤1. The stentectomy procedure using the defined technique is feasible to retrieve thrombosed stents and effective to restore the blood flow. It can be considered a last resort option to treat acute in-stent thrombosis resistant to alternative bail-out treatments.

Safety and efficacy of systematic lesion preparation with a novel generation scoring balloon in complex percutaneous interventions: results from a prospective registry.

Coronary lesions predilatation with semicompliant (SC) or non-compliant balloons (NC) may be insufficient to obtain an optimal stent expansion, which can lead to in-stent restenosis or thrombosis. Moreover, increasing evidence supporting an optimal lesion preparation is mandatory when drug coated balloons (DCB) are used. To this extent, more "aggressive tools" such as cutting/scoring balloons, atherectomy or lithotripsy may play an important role and improve outcomes. We enrolled 78 consecutive patients from March 2020 to October 2020 with calcific/fibrotic or ostially-located lesions, which were prepared using scoring balloons, in addition to SC/NC balloons and other plaque modification strategies. The final treatment consisted in either stent or DCB usage. The primary endpoint was the rate of clinically-driven target lesion revascularization. Secondary endpoints entailed the procedural success and the individual rates of major adverse cardiac events (MACE) at 12 months. Most of the patients had left main (LM) or ostial lesions, 65% of them being moderate/severely calcified, with further debulking strategies being required in 15 (19.2%) patients (rotational atherectomy, 3.8% or coronary intravascular lithotripsy, 15.3%). A high-rate of DCB usage was reported. Angiographic and procedural success was obtained in 77 and 76 patients, respectively. We encountered one vessel perforation, which was sealed with a covered stent, without consequence. During follo- up, we observed only 6 MACE, 6 target lesion revascularizations (TLR) and 2 cardiovascular deaths. Among patients with high complexity and calcific lesions, an optimal lesion preparation using a dedicated scoring balloon was associated with low clinical events at mid-term follow-up and may be considered to improve immediate procedural success rate.

A retrospective observational study compared the efficacy of pneumatic and holmium laser ureteroscopic lithotripsy for treatment of ureteral stones

Purpose: To compare the efficacy and complications of holmium laser lithotripters and pneumatic lithotripters, the two most commonly used lithotripters in the endoscopic treatment of ureteral stones, at all ureteral levels. Material and method: Retrospective data on 510 patients who had ureterorenoscopic lithotripsy performed by a single surgeon between January 2018 and 2021 were studied. Patients were divided into two groups: those who received a holmium laser lithotripter and those who received a pneumatic lithotripter. Demographic information, stone-free rates, double-j (JJ) stent usage, JJ stent removal time, type of anesthesia, operation time, hospital stay, and complication rates were all examined. Results: The patient numbers in the holmium laser and pneumatic groups were 265 and 245, respectively. The overall success rate in group 1 was found to be significantly higher than in group 2 (98.5 percent vs 93.9 percent; p=0.006). Group 1 had a significantly higher success rate in proximal ureteral stones (94.4 percent vs 68.9 percent; p=0.001). Patients in group 1 had a significantly higher rate of not using any ureteral stent (29.8 percent vs 17.6 percent; p<0.001). There was no difference between the two groups in terms of mid-ureter and distal ureter stones, anesthesia type, operation time, hospital stay, JJ stent removal time, and complications. Conclusion: For ureteral stones, ureterorenoscopic lithotripsy is the chosen therapeutic approach. The location of the stone in the ureter as well as the type of lithotripters used can have an impact on the outcome. Because of its great efficiency and lack of need for ureteral stents, holmium laser lithotripsy may be preferred for the treatment of proximal ureteral stones.

Outcome of stented versus unstented mid-shaft to distal hypospadias repair

AimsWe compared the outcomes of unstented repair (UR) versus stented repair (SR) in patients with mid-shaft to coronal hypospadias (HS) to elucidate if SR has any advantage over the UR.Materials and Methods:We retrospectively studied our mid-shaft to coronal HS repair patients between January 2013 and January 2018. We recorded variables such as degree of HS, age at repair, surgeon, type of repair, suture used, stent usage, and standard early and late complications. Relative risk (RR) was calculated and P < 0.05 was considered significant.Results:We included 120 patients (63 UR, 57 SR). There was no statistically significant difference in any parameters in both the groups. All had either tubularized incised plate or Thiersch–Duplay procedure. Urethroplasty was done with PDS 6/0 in all cases. Trainees performed two-third of the repairs under variable supervision. Early complications included one UR patient having urinary retention needing insertion of urethral catheter, five SR patients having bleeding/swelling, and three UR having dysuria. All were managed conservatively. For late complications, 98 patients were available (UR: 51, SR: 47) with fistula in 17 (17.3%), UR 8 (15.6%) versus SR 9 (19.1%) (P = 0.5, RR = 1.2) meatal stenosis in 3, UR 3 versus SR 0 (P = 0.06, RR = 6.4) and glanular dehiscence 6, UR 4 versus SR 2 (P = 0.25, RR = 1.8).Conclusion:There were no statistically significant differences in the short-term complications between UR and SR for HS. In the long term, RR for meatal stenosis is higher in UR.

Impact of Coronary Stent Price Regulation Section on the Interventional Cardiology Landscape of India: An Assessment of Health Economics Outcomes

Introduction: The cases of Coronary Artery Diseases (CAD) are on the rise in India, this can be attributed to various factors such as ageing, lifestyle, smoking, food habits, and higher income levels. Although, a large proportion of India’s population has access to some form of health insurance, the out of pocket expenditure is still extremely high as a percentage of total health spendings. Aim: To assess the impact of coronary stent price regulation on the interventional cardiology field in India. Materials and Methods: Retrospective data for this study was collected from online search at google and various other external data sources such as websites and published reports of World Health Organisation (WHO), Niti Aayog, National Pharmaceuticals Pricing Authority (NPPA) and Economic Times (ET) Health World. Line graphs for the percentage change in the number of percutaneous coronary intervention procedures, usage of Drug Eluting Stents (DES) pricing for government and private hospitals for the period 2016-2021 were plotted using Microsoft excel. Results: A high cost of coronary stents ranging from Indian Rupee (INR) 40,000 to INR 1,25,000 was a major contributor to a very high out of pocket expenditure in the field of interventional cardiology. In order to curtail this cost, a ceiling limit of INR 29,600 was imposed with respect to the prices of coronary stents in the year 2017 by the NPPA. Ever since a ceiling limit was imposed on the prices of coronary stents in India, there has been an annual increase of 3.7%, 13.1%, 12.6%, and 12.9% in the number of coronary intervention procedures for the years 2017, 2018, 2019 and 2021, respectively. Similarly, the usage of DES has also shown an annual increase of 8.9%, 14.7%, 10.5%, and 13.3%, respectively for the same years. Conclusion: At this juncture when the burden of CAD is on a rise in India, the efforts to make coronary stents more affordable will go a long way in the efficient management of CAD in the country.

POSB415 Predicting Factors of Complicated Ureteral Stent Removal in Patients with Kidney Stone in the United States

Cystoscopy-based stent removal (CBSR) is a common procedure following ureteroscopy with stent placement. Complicated stent removal CPT® code 52315 is designated for encrusted stents as defined by the AUA. No previous research has examined the stent removal usage pattern in a real-world practice. This study investigated factors associated with complicated stent removal among commercially insured patients in the US.

Bladder Recurrence Following Diagnostic Ureteroscopy in Patients Undergoing Nephroureterectomy for Upper Tract Urothelial Cancer: Is Ureteral Access Sheath Protective?

ObjectiveTo examine the effect of diagnostic ureteroscopy (URS) and ureteral access sheath usage on bladder recurrence following radical nephroureterectomy (RNU). MethodsWe retrospectively reviewed the records of patients who underwent RNU between 2005 – 2019. Patients with a history of bladder cancer and those without a bladder cuff resection were excluded. Bladder recurrence was the primary outcome and cox regression modeling was used to assess the impact of URS adjusting for other factors. ResultsOut of 271 RNU cases, 143 were included with a median age of 73 years (IQR 65 – 80). URS was performed in 104 cases (73%) and a ureteral access sheath was used in 26 (25%). With a median follow-up of 27 months, there were 36 (25%) bladder recurrences. The bladder recurrence rate (median time to recurrence) for patients who had URS vs no URS was 30.8% (9.0 months) and 7.7% (12.1 months), respectively (P = .02). A lower recurrence rate was noted in patients whom a ureteral access sheath was utilized (11.5%) vs those with no access sheath (39.7%, P = .01). Multivariable analysis revealed a significant increase in bladder recurrence if URS was performed prior to RNU (HR 5.6 [1.7 – 18.5], P <.004), however, this effect was mitigated if a ureteral access sheath was used (HR 1.3, [0.3 – 6.4], P = .76). Ureteral stent usage and performing a ureteroscopic biopsy had no significant effect on bladder recurrence. ConclusionDiagnostic URS in patients undergoing RNU for UTUC significantly increases the risk of bladder recurrence. This effect may be mitigated by using a ureteral access sheath.

Usage and Efficiency of Drug Eluting Stents in Vertebral Ostial Stenosis

Objectives: Extracranial vertebral artery atherosclerosis is an insidious and hazardous disease. With technological development and accumulating experience, antiproliferative drug eluting stents became a viable option for reducing the instent restenosis of the origin of the vertebral artery. Here, we evaluated the technical success rates, efficiency, clinical and angiographic results of the usage of drug eluting stents in vertebral ostial stenosis. Patients and Methods: 28 stents were implanted in 24 patients with vertebral artery origin stenosis. Digital substraction angiographic or CT angiographic follow-up was made at 6, 12 and 24 months. Results: Paclitaxel eluting stents were placed with high technical success for the treatment of vertebral artery origin stenosis. There was no procedure related mortality. However one patient scummed to death due to aspiration pneumonia for a basiller artery stroke with successful stenting and thrombolysis procedure. There was only one limited subclavian artery dissection in a patient (%4.1) during the procedure which was managed conservatively. One stent (%3.7) had instent restenosis on early period (6th month) and one patient (%4.1) had recurrent neurological symptoms on follow-up (9th month). In a median follow-up of 13 months (6-25 months) none of the patients had late stent thrombosis. Conclusion: Vertebral artery ostial stenosis can be treated effectively and safely with high technical success and low instent restenosis rates with paclitaxel drug eluting stents. With low restenosis rates the antiproliferative drug eluting stents are an option for reducing the vertebral artery instent restenosis.

Single-Session Mechanical Thrombectomy of Lower Extremity Deep Venous Thrombosis Using the ClotTriever System: A Single-Institution Experience

Abstract Purpose The aim of this study was to provide a single-center experience in utilization of the ClotTriever mechanical thrombectomy system in acute and subacute deep vein thrombosis (DVT). Methods Retrospective review was performed for all patients who underwent DVT thrombectomy using the ClotTriever system at a single academic medical center. Data recorded included age, gender, etiology, laterality of DVT, fluoroscopy time, perioperative parameters, type of anesthesia, concomitant usage of thrombolytics and/or stents. Follow-up Doppler ultrasounds or diagnostic venograms were reviewed, and time of reintervention (if performed) and Villalta scores were recorded. Results Ten patients were included in the study, with 6/10 female (60%), mean age 54.6 years (range: 24–80). Eight patients presented with acute iliofemoral DVT, one patient with subacute iliofemoral DVT, and one patient with subacute inferior vena cava thrombosis. Only one patient required concomitant intraprocedural thrombolytic administration, and four patients underwent same-session venous stent placement. Technical success was achieved in 90% patients and no procedure-related adverse events were observed. Reintervention within 30 days was required in two (20%) patients at 12 and 13 days. No patient required intensive care unit (ICU) stay, and mean postprocedure hospital length of stay was 2.3 days. On follow-up (mean: 214 days), five patients had no evidence of DVT and four patients showed chronic postthrombotic changes in femoropopliteal veins not requiring intervention. Conclusion The ClotTriever mechanical venous thrombectomy system demonstrates high efficacy in removal of thrombus from lower extremities in a single session, often obviating the need for thrombolytic therapy with low reintervention rates and short postprocedure hospital stay.

Abstract P561: Efficacy of Beveled Tip Aspiration Catheter in Mechanical Thrombectomy for Acute Ischemic Stroke

Introduction: The ADAPT technique uses large bore aspiration catheters for mechanical thrombectomy. Several aspiration catheters are now available. We report a bench-top exploration of a beveled-tip catheter, and our experience in treating large vessel occlusions using next-generation aspiration catheters. Methods: Twenty experiments were conducted with either a Sofia Plus or a Zoom71 using a vascular phantom in which a clot model was introduced. Rate of ingestion, complete recanalization after a single attempt, and pressure at the catheter tip for both devices were recorded. A retrospective analysis from a prospectively-maintained database was performed. Patient demographics, periprocedural metrics, discharge and 90-day modified Rankin Scales were collected. Patients were divided into two groups based on which aspiration catheter was used. Results: In our bench-top experiment, complete ingestion of the clot occurred in 90% of beveled tip and 20% of control device experiments (p=0.006). Our clinical data demonstrated no significant difference in age, gender, IV tPA administration, admission NIHSS, baseline mRS, or LVO location between the beveled tip and flat tip groups. With the beveled tip, TICI 2C or better recanalization was more frequent (93.2% vs 74.2%, p-value 0.017), stent retriever usage was lower (9.1% versus 29%, p-value 0.024), and patients had lower mRS on discharge (median 3 vs 4, p less than 0.001) and at 90 days (median 2 vs 4, p=0.008). Conclusion: The beveled tip design leads to more frequent clot ingestion in a bench top model, which may translate into a more efficacious thrombectomy device with improved outcomes.

Tandem ureteral stents drainage lowers renal pelvis pressure in malignant ureteral obstruction: Experimental and computational models

Malignant ureteral obstruction may lead to impaired renal function and requires drainage by a percutaneous nephrostomy tube or an internal ureteric stent. Usage of stiff tandem ureteral stents may decrease stent failure rates. In this paper we combined computational and in vitro models to examine the flow in a malignant ureteral obstruction (MUO) managed by 4 methods of drainage: single soft stent, single stiff stent, soft tandem ureteral stents, and stiff tandem ureteral stents. Pressure at the renal pelvis was the primary outcome of the computational and in vitro models. Different drainage modalities were compared using ANCOVA. Results of computational and in vitro models agreed completely. Drainage by stiff tandem ureteral stents provides lower renal pelvis pressure levels compared with single and soft stents (p < 0.001), especially for high levels of external pressure. Usage of stiff tandem ureteral stents may decrease stent-failure rates and postpone the need for percutaneous nephrostomy tube insertion.

CORRIGENDUM

Catheterization and Cardiovascular InterventionsVolume 97, Issue 3 p. 567-567 ERRATUMFree Access CORRIGENDUM This article corrects the following: Cover up: Clinic outcomes of covered stent usage for coronary perforation during PCI David Elison MD, Larry S. Dean MD, Volume 96Issue 7Catheterization and Cardiovascular Interventions pages: 1367-1368 First Published online: December 11, 2020 First published: 05 January 2021 https://doi.org/10.1002/ccd.29454AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat In [1], the following error was published in the article title. Cover up: Clinic outcomes of covered stent usage for coronary perforation during PCI. The text was incorrect and should have read: Cover Up: Clinical Outcomes of Covered Stent Usage for Coronary Perforation during PCI. The authors apologize for this error. REFERENCE 1Elison D, Dean LS. Cover up: Clinic outcomes of covered stent usage for coronary perforation during PCI. Catheter Cardiovasc Interv. 2020; 96: 1367- 1368. https://doi.org/10.1002/ccd.29400. Wiley Online LibraryPubMedWeb of Science®Google Scholar Volume97, Issue3February 15, 2021Pages 567-567 ReferencesRelatedInformation

Stenting for colorectal cancer obstruction in Icelandic patients

Self-expandable metal stents (SEMS) are a known treatment option for obstruction due to colorectal cancer. The objective of this project was to estimate the usage of such stents in Iceland between 2000-2018. We evaluated the number of patients who received the stent as a bridge to surgery (BtoS) or as a palliative therapy (PT) and evaluated complication rate and the technical and clinical success rate. Retrospective review of patients in Landspitali University Hospital who received SEMS for malignant colorectal obstruction. Search was conducted using diagnostic and theraputic codes in the Icelandic electronic medical record system. A total of 43 patients with colorectal cancer received in total 53 SEMS for obstruction, the first patient in 2005. More patient received SEMS as PT (n=27) than as BtoS (n=16). Colon perforation occurred in 5 patients (12%). A resection with primary anastomosis was performed in 69% of the BtoS patients. The majority of the PT patients did not receive an operation (63%). Permanent stoma ratio was 27% for BtoS patients and 22% for PT patients. SEMS served as BtoS with resection and primary anastomosis for the majority of patients in the BtoS group. For a majority of patients in the PT group, SEMS could be used to avoid surgery. The perforation rate was relatively high. Information on techincal and clinical success was poorly recorded. Because of the retrospective nature of the study and the small population size all results should be interpreted with caution.

Cover up: Clinic outcomes of covered stent usage for coronary perforation during PCI

Coronary artery perforation is an uncommon, but potentially devastating, complication of PCI, and is observed most frequently in complex procedures. Clinical outcomes, including periprocedural and long-term mortality, are markedly worse with increasing degree of perforation. Perforation required covered stent usage predicts a high in-hospital and overall mortality, although no difference is noted between covered stent type.

Efficacy of beveled tip aspiration catheter in mechanical thrombectomy for acute ischemic stroke

BackgroundDirect aspiration thrombectomy techniques use large bore aspiration catheters for mechanical thrombectomy. Several aspiration catheters are now available. We report a bench top exploration of a novel beveled tip catheter...

Bile Duct Injury: Surgical Use of Endobiliary Stents for the Management in Emergency Situations

This study reviews bile duct injuries (BDI) most commonly found in our setup and a novel technique of endobiliary stent usage for management in emergency situations leading to significantly less morbidity and mortality. A total of 211 patients were analyzed out of 214 BDI. All the data regarding demographic details, time of injury, time to referral, surgeons’ perception of anatomy, anatomical variance, and the type of presentation were collected. We propose a new technique and management guideline in the current era of endoscopy and surgery together for the treatment of BDI and benign biliary stricture. We have observed that the mean age was 45.5 years. Out of 211 cases, 175 were after laparoscopic cholecystectomy. Exploration and external drainage of bile was done in initial 12 patients, out of which 3 patients had a combined endobiliary surgical internal stent and T tube. Later on, all patients (38) were internally drained with endobiliary stents. All patients of minor bile duct injury were managed with endoscopic retrograde cholangiography and papillotomy, and endobiliary plastic stenting. Overall, 76% of patients with biliary laceration and segmental injury (less than 1 cm) were managed with endoscopic stent techniques, without definitive surgery. Only 24% of the patient with minor or less than 1-cm laceration group of patients needed hepatico jejunostomy (HJ) along with all major-type bile duct injuries. We propose the use of an endobiliary plastic stents for internal drainage and repair of BDI in emergency and intraoperative situations in order to avoid long-term external drains as well as nutritional and electrolytes issues following high-output biliary fistula. Furthermore, it prevents the progression of biliary stricture.

Outcomes with ureteral access sheath in retrograde intrarenal surgery: a retrospective comparative analysis.

ABSTRACTBACKGROUND: Retrograde intrarenal surgery is used for treatment of urinary system stones. The ureteral access sheath (UAS) is used to decrease intrapelvic pressure, help with access of multiple instruments, and facilitate drainage and removal of the fragmented stones.OBJECTIVE: Assess the effect of the UAS on the outcomes of retrograde intrarenal surgery.DESIGN: A retrospective patient data review.SETTING: Training and research hospital in Turkey.PATIENTS AND METHODS: We reviewed the data of patients who had undergone retrograde intrarenal surgery between 2012-2019. Patients who had kidney anomalies, were <18 years old, and who had ureteral and urethral strictures were excluded from the study. The demographic characteristics, stone type, complications, intraoperative and postoperative data of the patients were reviewed. A successful outcome was defined as being stone free or having clinically insignificant residual fragments (<3 mm). The use of the UAS was compared with other procedures in terms of efficiency and safety. Factors determining UAS usage were assessed by multivariate analysis.MAIN OUTCOME MEASURES: Stone free rate and complication rate in patients who underwent retrograde intrarenal surgery.SAMPLE SIZE: 1808 patients met inclusion criteria.RESULTS: The UAS was used in 1489 procedures, while other methods were used in 319 procedures. Operation time was 46.9 (17.3) minutes and 42.9 (19.0) minutes with other methods. Postoperative double J stent usage rates were 88.2% and 63% in the UAS and other methods, respectively. The rate of successful outcome was 88.2% and 81.2% in the UAS and other methods, respectively (P<.001). The rate of complications was similar in both groups (P=.543). In a multivariate analysis, UAS usage was directly proportional with stone size and inversely proportional with preoperative JJ stent usageCONCLUSION: The UAS can be effectively and successfully used in retrograde intrarenal surgery for treatment of urinary system stones. UAS usage should be considered for the patients who have large stones (2 cm) and do not have a preoperative double J stent.LIMITATIONS: Retrospective design.CONFLICT OF INTEREST: None.

Su1287 TIMING OF DIRECT ENDOSCOPIC NECROSECTOMY THROUGH LUMEN-APPOSING METAL STENTS FOR WALLED-OFF PANCREATIC NECROSIS IMPACTS TIME TO RESOLUTION

Lumen-apposing metal stents (LAMS) are effective in resolving walled-off pancreatic necrosis (WON) and provide a conduit for direct endoscopic necrosectomy (DEN). However, the decision to perform, or the timing of DEN to facilitate resolution, is not well-defined. We aimed to determine if early DEN was associated with shorter time to resolve WON. A retrospective review of our endoscopy database identified WON patients who underwent LAMS. Patient demographics, WON characteristics, number of DEN, and outcomes were compiled. Subgroups by timing of DEN included concomitant DEN (CDEN; index DEN at time of LAMS placement) or delayed DEN (DDEN; index DEN at a later date). Patient demographics, procedure details, and outcomes were compared between groups using the Wilcoxon rank-sum test. Linear regression was performed to identify predictors for time to WON resolution. Variables significant at p <0.2 on univariate analysis were included in the multivariate model. Cox proportional hazards regression was performed to identify risk factors for resolution. Variables significant at p <0.2 on univariate analysis were included in the multivariate model. Nelson-Aalen cumulative hazards curves were constructed to depict time to resolution stratified by timing of index DEN. The primary outcome was time to resolution of WON, determined radiographically or endoscopically. Secondary outcomes included adverse events (see table) and total number of DEN sessions required. Between 1/11 and 6/19, 175 patients underwent LAMS for peripancreatic fluid collections. 155 (88.6%) were WON of which 50/155 (32.3%; 80% male, 52.5 years old) required DEN and comprised the study cohort. The size of WON and use of double pigtail stents through the LAMS was similar between groups. Overall, the mean time to resolution of WON (see figure) was 90.6 days with a mean of 44.5 days in CDEN vs. 100.7 days in DDEN (p=0.02) despite similar number of DEN between groups (p= 0.64). All patients in both groups had radiographic or endoscopic WON resolution. Mean length of stay was also significantly different between groups at 0.9 vs 14.7 days (p=0.03). Total number of adverse events were 5 in the CDEN vs 45 in the DDEN (p=0.45). In multivariate analysis, higher number of double pigtail stent usage through LAMS was associated with a longer time to WON resolution (Multivariate β coefficient (95% CI): 51.4 (22.8-80.1), p=0.005) suggesting greater complexity. 1) In our cohort of WON patients treated with LAMS, only one-third required DEN. 2) Despite a similar number of total DEN, concomitant LAMS and DEN performance during the index endoscopic session resulted in a significantly shorter time to resolution and did not require percutaneous drainage compared with DEN performed at a subsequent session. 3) The adverse event rates between groups were similar.FigureKaplan-Meier Curves of Resolution of Walled-off Necrosis by Timing of Necrosectomy (top pane) and Cumulative Probability of Resolution of Walled-off Necrosis (bottom pane)View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Real-World Practice Patterns in the Era of Rectal Indomethacin for Prophylaxis Against Post-ERCP Pancreatitis in a High-Risk Cohort.

The benefit of indomethacin suppositories for prophylaxis against post-ERCP pancreatitis (PEP) in high-risk patients was established in a landmark trial published in 2012. The aims of this study were to measure the adoption of indomethacin prophylaxis in widespread clinical practice, evaluate concurrent trends in pancreatic duct (PD) stent utilization, and estimate the impact of these changes on PEP in a high-risk population. Data were extracted from a commercial database (Explorys, IBM Watson Health, Somers, NY) that aggregates electronic health records from 26 US healthcare systems from 2009 to 2018. Using Systematized Nomenclature of Medicine Clinical Terms, we identified a cohort of patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) and were at high risk for PEP based on narrow criteria. PEP was defined as an emergency department or hospital admission 1-5 days after ERCP with an associated diagnosis of pancreatitis. Twenty six thousand eight hundred twenty ERCPs were performed on this high-risk cohort from 2009 to 2018. The overall PEP rate during the study period was 8.6%. There was no decrease in PEP rates from 2012 to 2018. Beginning in 2012, indomethacin usage increased linearly (P < 0.001), but remained below 50% in 2018. As indomethacin increased, utilization of PD stents declined abruptly from 2013 to 2014 (40.7%-8.5%) and trended to a nadir of 3.0%. Despite its low cost, widespread availability, and level I evidence of benefit in reducing the risk of PEP in high-risk patients, the adoption of rectal indomethacin during ERCP has been slow and the medication continues to be under-utilized. In parallel, the PD stent usage has declined dramatically. The lack of change in PEP rates during the study period could be attributable to the persistent low usage of rectal indomethacin or the decline in PD stent use. Further educational efforts and quality assurance measures are warranted to ensure that rectal indomethacin and PD stent placement are more appropriately used in clinical practice.