Stent Group Research Articles

MP32-06 EARLY STENT REMOVAL AFTER RADICAL CYSTECTOMY

You have accessJournal of UrologyCME1 Apr 2023MP32-06 EARLY STENT REMOVAL AFTER RADICAL CYSTECTOMY Jessica Wenzel, Solange Bassale, Paul Jones, Eric Robinson, Sudhir Isharwal, Christopher Amling, Kamran Sajadi, and Jen Jane Liu Jessica WenzelJessica Wenzel More articles by this author , Solange BassaleSolange Bassale More articles by this author , Paul JonesPaul Jones More articles by this author , Eric RobinsonEric Robinson More articles by this author , Sudhir IsharwalSudhir Isharwal More articles by this author , Christopher AmlingChristopher Amling More articles by this author , Kamran SajadiKamran Sajadi More articles by this author , and Jen Jane LiuJen Jane Liu More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003265.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Extended antibiotic prophylaxis after radical cystectomy (RC) reduces urinary tract infections (UTI) and urosepsis. Optimal duration of prophylaxis remains unknown as ureteral stents are associated with an increased risk of UTI. Similarly, the optimal duration and benefit of ureteral stents is unknown, with trends toward removing stents earlier or foregoing them altogether. Our protocol after RC previously consisted of ureteral stent duration of at least 14 days and 30 days of antibiotic prophylaxis postoperatively. To reduce stent duration and antibiotic exposure, we changed our protocol in 2020 to remove stents prior to discharge and stop antibiotic prophylaxis earlier (14d). We assessed rates of UTI and urine leak in our cohort of patients undergoing RC during this change. METHODS: We performed a retrospective chart review of all patients who underwent radical cystectomy for bladder cancer at our institution between 2016-2022(OHSU IRB approved). Patients were stratified into early or late stent removal ( <14 or >14 days post-operatively). The primary outcomes were incidence of UTI (defined as positive urine culture requiring antibiotic treatment) and urine leak, as measured by postoperative drain creatinine measurement greater than twice serum creatinine Statisical analysis was performed using Wilcoxon test and chi-square analysis. RESULTS: Of 221 patients with evaluable data, 33% of patients had early and 67% had late stent removal. Mean day of stent removal was 8.0 versus 19.9 in the early versus late group. Antibiotic exposure was lower in the early stent removal group (10 vs 21 days, p≤0.05). There was no difference in rate of postoperative UTI when comparing early versus late stent removal (10.8% vs 10.2%, p=0.9). Similarly, there was no difference in rate of urine leak when comparing early versus late stent removal (0% vs 1.3%, p=0.31). Readmission rates were similar for early versus late stent removal (7 vs 12%, p=0.3). CONCLUSIONS: Earlier stent removal and reduced duration of antibiotic prophylaxis after RC does not result in an increased rate of UTI or urine leak. Decreasing ureteral stent duration reduces postoperative antibiotic exposure without increasing adverse outcomes in patients undergoing RC. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e442 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jessica Wenzel More articles by this author Solange Bassale More articles by this author Paul Jones More articles by this author Eric Robinson More articles by this author Sudhir Isharwal More articles by this author Christopher Amling More articles by this author Kamran Sajadi More articles by this author Jen Jane Liu More articles by this author Expand All Advertisement PDF downloadLoading ...

MP35-07 IMPACT OF PREOPERATIVE URETERAL STENTING SIZE ON POSTOPERATIVE OUTCOMES OF RETROGRADE INTRARENAL SURGERY FOR UROLITHIASIS: A PROSPECTIVE STUDY

You have accessJournal of UrologyCME1 Apr 2023MP35-07 IMPACT OF PREOPERATIVE URETERAL STENTING SIZE ON POSTOPERATIVE OUTCOMES OF RETROGRADE INTRARENAL SURGERY FOR UROLITHIASIS: A PROSPECTIVE STUDY Kyu Won Lee, Sae Woong Choi, Kyu Hun Han, and Hyuk Jin Cho Kyu Won LeeKyu Won Lee More articles by this author , Sae Woong ChoiSae Woong Choi More articles by this author , Kyu Hun HanKyu Hun Han More articles by this author , and Hyuk Jin ChoHyuk Jin Cho More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003269.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: It is widely known that preoperative ureteral stenting (pre-stenting) prevents intraoperative ureteral injury and increases the success rate of access sheath placement in retrograde intrarenal surgery (RIRS). However, many patients suffer from stent-related symptoms such as urinary symptoms, flank pain and hematuria. The aim of this study is to assess the outcome of RIRS and perioperative pain according to the size of the stent used for pre-stenting. METHODS: A prospective study was conducted on patients who went RIRS from March 2019 to April 2022. Patient’s demographics, stone characteristics, postoperative outcomes and perioperative pain scale were compared based on the preoperatively placed ureteral stent size. RESULTS: A total of 76 patients were included in this study. 44 were placed with 4.7 Fr ureter stent (Group I) and 32 were placed with 6.0 Fr ureter stent (Group II) before surgery. Patient demographics, stone characteristics and duration of pre-stenting were similar. There was no difference in operative outcomes, including operation time, length of stay, and stone free rate between the two groups. As a postoperative complication, one urticaria and one urethral stenosis occurred in group I, while urinary tract infection occurred in two in group II (p=0.521). Pain assessed using visual analogue scale (VAS) three times during the period from pre-stenting to surgery was significantly lower in Group I (p<0.05 for all). Urinary irritation symptoms (p<0.001) and hematuria (p=0.005) that occurred after pre-stenting were also less observed in Group I. VAS measured after RIRS did not differ at 2, 8, 24 hours after surgery (p=0.490, 0.129, 0.138), but it was measured lower in Group I at discharge (p=0.07). There was no difference in the amount of analgesics used after surgery between the two groups (p=0.338). CONCLUSIONS: Pre-stenting with 4.7 Fr ureteral stent is a safe and effective method, especially to improve stent-related symptoms and pain. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e470 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kyu Won Lee More articles by this author Sae Woong Choi More articles by this author Kyu Hun Han More articles by this author Hyuk Jin Cho More articles by this author Expand All Advertisement PDF downloadLoading ...

MP35-01 A SINGLE CENTRE PROSPECTIVE RANDOMIZED CONTROLLED STUDY TO ASSESS OUTCOMES AND COMPLICATIONS OF CONVENTIONAL STENT PLACEMENT VERSUS NO STENT PLACEMENT AFTER URETEROSCOPY FOR DISTAL URETERIC CALCULUS OF SIZE &lt; 1 CMS

You have accessJournal of UrologyCME1 Apr 2023MP35-01 A SINGLE CENTRE PROSPECTIVE RANDOMIZED CONTROLLED STUDY TO ASSESS OUTCOMES AND COMPLICATIONS OF CONVENTIONAL STENT PLACEMENT VERSUS NO STENT PLACEMENT AFTER URETEROSCOPY FOR DISTAL URETERIC CALCULUS OF SIZE <1 CMS Arun Chawla, Suraj Jaidev Reddy, and Jean de la Rosette Arun ChawlaArun Chawla More articles by this author , Suraj Jaidev ReddySuraj Jaidev Reddy More articles by this author , and Jean de la RosetteJean de la Rosette More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003269.01AboutAbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Abstract INTRODUCTION AND OBJECTIVE: Most Endo-urologists routinely insert ureteric stents, justified by the hypothetical fact that stent placement promotes the passage of residual stone fragments and clots, presumably lowers the risk of stricture formation, and prevents ureteric obstruction and renal colic induced by ureteric oedema We aimed to compare the efficacy, safety and morbidity of No stent placement with the conventional stent placement after uncomplicated retrograde semi rigid URSL for distal ureteric calculus of size <1 cm pertaining to Lower Urinary tract symptoms and Sexual function using validated questionnaires. In addition, to compare complication rate, emergency visits, secondary interventions and pain at the time of follow up using visual analog scale (VAS) between the two groups. METHODS: 104 patients were randomized following an uncomplicated ureteroscopic lithotripsy into Conventional stented Group (CSG) and non-stented group (NSG). Lower urinary tract symptoms and sexual function were evaluated using validated questionnaires (IPSS+IIEF-5+MSHQ-EjD/FSFI) preoperatively and at 4 weeks during follow up/ stent removal based on the group. Pain scores at follow up/ stent removal were recorded using a visual analogue scale (VAS). Patients who had emergency room visits, need for secondary interventions before the recommended time of follow up were noted. Generalized Estimating Equations method was used to explore the difference in change in the domains of IPSS, IIEF-5, MSHQ-EjD and FSFI between the two groups over time. RESULTS: Significant difference was noted in the following IPSS domains: Frequency, Urgency, Nocturia, Storage symptoms, Total IPSS Score (p=<0.001) and QoL (p=0.002), IIEF-5 domains: Overall Score (p=0.004), MSHQ-EjD domains, Ejaculation Bother/ Satisfaction (p=<0.001) and FSFI domains: Lubrication (p=<0.001), Satisfaction (p=0.006) and Overall Score (p=0.004). There was no significant difference between the various groups in terms of distribution of Emergency Visits, Readmission and Secondary Interventions, pain at follow-up (VAS) and long-term analgesia. CONCLUSIONS: Non placement of stents after uncomplicated URS decreases stent related symptoms, improves QoL without jeopardizing for an increased postoperative risk. Header Variable CSG Group (n=49) NSG Group (n=43) p-Value χ2 Header Emergency visits 7(14.3%) 5 (11.6%) 0.706 0.143 Header Readmissions 4 (8.2%) 1 (2.3%) 0.367 1.519 Secondary Interventions Conservative Management 0 (0.0%) 1 (2.3%) 0.467 1.152 Early stent removal 3 (6.1%) NA - - PCN Insertion 0 (0.0%) 0 (0.0%) - - Relook URS 1 (2.0%) 0 (0.0%) 1.000 0.887 Analgesia requirement (> 5 days) 11 (22.4%) 5 (11.6%) 0.172 1.867 Variable CSG Group (n=49) NSG Group (n=43) p-Value χ2 Emergency visits 7(14.3%) 5 (11.6%) 0.706 0.143 Readmissions 4 (8.2%) 1 (2.3%) 0.367 1.519 Secondary Interventions Conservative Management 0 (0.0%) 1 (2.3%) 0.467 1.152 Early stent removal 3 (6.1%) NA - - PCN Insertion 0 (0.0%) 0 (0.0%) - - Relook URS 1 (2.0%) 0 (0.0%) 1.000 0.887 Analgesia requirement (> 5 days) 11 (22.4%) 5 (11.6%) 0.172 1.867 Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e468 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Arun Chawla More articles by this author Suraj Jaidev Reddy More articles by this author Jean de la Rosette More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

New Diffusion Abnormalities Following Endovascular Treatment for Intracranial Atherosclerosis.

Background There are limited data on new ischemic brain lesions after endovascular treatment for symptomatic intracranial atherosclerotic stenosis (ICAS). Purpose To investigate the (a) characteristics of new ischemic brain lesions at diffusion-weighted MRI (new diffusion abnormalities) after endovascular treatment, (b) characteristics between those treated with balloon angioplasty and stent placement procedures, and (c) predictors of new ischemic brain lesions. Materials and Methods Patients with symptomatic ICAS in whom maximum medical therapy failed were prospectively enrolled between April 2020 and July 2021 from a national stroke center and underwent endovascular treatment. All study participants underwent thin-section diffusion-weighted MRI (voxel size, 1.4 × 1.4 × 2 mm3 with no section gap) before and after treatment. The characteristics of new ischemic brain lesions were recorded. Multivariable logistic regression analysis was performed to determine potential predictors of new ischemic brain lesions. Results A total of 119 study participants (mean age, 59 years ± 11 [SD]; 81 men; 70 treated with balloon angioplasty and 49 with stent placement) were enrolled. Of the 119 participants, 77 (65%) had new ischemic brain lesions. Five of the 119 participants (4%) had symptomatic ischemic stroke. New ischemic brain lesions were located in (61%, 72 of 119) and/or beyond (35%, 41 of 119) the territory of the treated artery. Of the 77 participants with new ischemic brain lesions, 58 (75%) had lesions located in peripheral brain areas. There was no evidence of a difference in the frequency of new ischemic brain lesions between the balloon angioplasty and stent groups (60% vs 71%, P = .20). In adjusted models, cigarette smoking (odds ratio [OR], 3.6; 95% CI: 1.3, 9.7) and more than one operative attempt (OR, 2.9; 95% CI: 1.2, 7.0) were independent predictors of new ischemic brain lesions. Conclusion New ischemic brain lesions on diffusion-weighted MRI scans were common after endovascular treatment for symptomatic intracranial atherosclerotic stenosis, and occurrence may be associated with cigarette smoking and the number of operative attempts. Clinical trial registration no. ChiCTR2100052925 © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Russell in this issue.

Early Results of the Newly-Designed Flowdynamics Dense Mesh Stent for Residual Dissection After Proximal Repair of Stanford Type A or Type B Aortic Dissection: A Preliminary Single-Center Report From a Multicenter, Prospective, and Randomized Study

Background: Negative remodeling of the distal aorta due to residual dissection significantly impacts the long-term outcomes of dissection patients after proximal repair of acute aortic dissection. Branched/fenestrated aortic stents are technically demanding, and studies of the first generation of multilayer flow modulators for tackling this clinical scenario are few and limited. The single-center results from a multicenter, prospective, and randomized controlled study aimed to verify the safety and effectiveness of a newly-designed flowdynamics dense mesh stent for treating residual dissection after proximal repair. Methods: Patients with nonchronic residual dissection involving visceral branches were prospectively enrolled in 3 centers (ChiCTR1900023638). Eligible patients were randomly assigned to the flowdynamics dense mesh stent (FDMS) group and control group. Follow-up visits were arranged at 1, 3, 6, and 12 months after recruitment. The primary endpoints were all-cause and aortic-related mortality. The secondary endpoints included visceral branch occlusion, reintervention, and severe adverse events. Morphological changes were analyzed to exhibit the therapeutic effect. Our center participated in the multicenter prospective randomized controlled trial, and the preliminary single-center experience was reported. Results: Thirty-six patients were enrolled in our center, and the baseline characteristics of the 2 groups were comparable. Thirty-four patients completed the 12 month follow-up. Freedom from all-cause and aortic-related death were 94.4% and 100%. All visceral branches remained patent in the FDMS group. Increased area of the true lumen (1.03±0.38 vs 0.48±0.63 cm2 at the plane below renal arteries, p=0.006; 1.27±0.80 vs 0.32±0.50 cm2 at the plane 5 cm below renal arteries, p<0.001) and decreased area of the false lumen at the plane below renal arteries (–1.03±0.84 vs −0.15±1.21 cm2, p=0.023) were observed in the FDMS group compared with those parameters in the control group. The FDMS group showed a significant increase in true lumen volume (p<0.001) and a significant decrease in false lumen volume (p=0.018). Conclusions: This newly-designed FDMS for endovascular repair of residual dissection after the proximal repair is safe and effective at 12 months. Clinical Impact One-year results of the randomized controlled clinical trial indicated the short-term safety and promising effect of FDMS on treating non-chronic residual dissection after proximal repair. At the 12th-month follow-up, the true lumen expanded, the false lumen shrunk and all visceral arteries kept patent. As far as I’m concerned, this is the first randomized controlled study concerning utilizing multilayer flow mesh stent treating aortic dissection. Despite a preliminary single-center report, our results are supposed to provide high-quality evidence to guide clinical practice and fill the gap in the application of FDMS.

Evaluation of pancreatic stent and/or suppository indomethacin efficacy in post ERCP pancreatitis prophylaxis: a single center experience

Aim: Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is a serious complication of ERCP. In this study, we aimed to compare the use of rectal indomethacin, pancreatic stenting or both techniques for prevention of PEP.&#x0D; Material and Method: Patients who underwent ERCP for the first time due to choledocholithiasis between January 2022 and June 2022 were retrospectively reviewed. The clinical findings, demographics, laboratory records, endoscopic intervention characteristics, whether rectal indomethacin was applied before the procedure, whether pancreatic stent was placed or not were evaluated.&#x0D; Results: A total of 367 patients who underwent ERCP for the first time were included in the study. The mean age was 61 (28-92) years and 53.4% were female. In 124 (33.8%) patients, involuntary guide-wire insertion into the pancreatic duct occurred during canulation. Pancreatic stent was placed in 82 (22.3%) of the patients. Rectal indomethacin was administered to 288 patients (78.5%), while indomethacin could not be administered in 79 patients (21.5%), because they did not give consent. When patients with involuntarily pancreatic canulation were evaluated, the rate of PEP was 3.6% in the stented group, while it was 15.3% in the stent-free group (p

Prospective, randomized, multicenter clinical study comparing a self-expanding covered stent to percutaneous transluminal angioplasty for treatment of upper extremity hemodialysis arteriovenous fistula stenosis

Use of a covered stent after percutaneous transluminal angioplasty (PTA) was compared to PTA alone for treatment of upper extremity hemodialysis patients with arteriovenous fistula (AVF) stenoses. Patients with AVF stenosis of 50% or more and evidence of AVF dysfunction underwent treatment with PTA followed by randomization of 142 patients to include a covered stent or 138 patients with PTA alone. Primary outcomes were 30-day safety, powered for noninferiority, and six-month target lesion primary patency (TLPP), powered to test whether TLPP after covered-stent placement was superior to PTA alone. Twelve-month TLPP and six-month access circuit primary patency (ACPP) were also hypothesis tested while additional clinical outcomes were observed through two years. Safety was significantly non-inferior while six- and 12-month TLPP were each superior for the covered stent group compared to PTA alone (six months: 78.7% versus 55.8%; 12 months: 47.9% versus 21.2%, respectively). ACPP was not statistically different between groups at six-months. Observed differences at 24 months favored the covered-stent group: 28.4% better TLPP, fewer target-lesion reinterventions (1.6 ± 1.6 versus 2.8 ± 2.0), and a longer mean time between target-lesion reinterventions (380.4 ± 249.5 versus 217.6 ± 158.4 days). Thus, our multicenter, prospective, randomized study of a covered stent used to treat AVF stenosis demonstrated noninferior safety with better TLPP and fewer target-lesion reinterventions than PTA alone through 24 months.

Long-term efficacy of metal versus plastic stents in inoperable perihilar cholangiocarcinoma; a multicenter retrospective propensity score matched comparison

BackgroundFor palliative drainage of inoperable perihilar cholangiocarcinoma (pCCA) uncovered metal stents are preferred over plastic stents. However, there is a lack of data on re-interventions at the long-term. The aim is to evaluate the potential difference in the number of re-interventions in patients surviving at least 6 months. MethodsRetrospective study including patients with pCCA who underwent plastic stent placement(s) or had metal stent(s) in situ for at least 6 months. The primary outcome was the number of re-interventions per patient-year. A propensity score matching (1:1) analysis was performed using age, Bismuth classification, reason for inoperability, pathological confirmation, systemic therapy and initial approach (endoscopic vs percutaneous). ResultsPatients in the metal stent group (n = 87) underwent fewer re-interventions compared with the plastic stent group (n = 40) (3.0 vs. 4.7 per patient-year; IRR, 0.64; 95% CI, 0.47 to 0.88). When only non-elective re-interventions were included, there was no significant difference (2.1 vs. 2.7; IRR, 0.76; 95% CI, 0.55 to 1.08). Results were similar in the propensity score-matched dataset. ConclusionsThis study shows that, also in patients with inoperable pCCA who survive at least 6 months, placement of metal stent(s) leads to fewer re-interventions in comparison with plastic stents.

Endoscopic biliary treatment of unresectable cholangiocarcinoma: A meta-analysis of survival outcomes and systematic review.

Endoscopic radiofrequency ablation (ERFA), percutaneous radiofrequency ablation (PRFA), and photodynamic therapy (PDT), when used in conjunction with conventional biliary stenting, have demonstrated a survival benefit in patients with unresectable cholangiocarcinoma. To compare pooled survival outcomes, adverse event rates, and mean stent patency for those undergoing these procedures. A comprehensive literature review of published studies and abstracts from January 2011 to December 2020 was performed comparing survival outcomes in patients undergoing ERFA with stenting, biliary stenting alone, PRFA with stenting, and PDT with stenting for unresectable cholangiocarcinoma (CCA). Data from four studies demonstrated a pooled mean survival favoring ERFA as compared to biliary stenting alone (12.0 ± 0.9 mo vs 6.8 ± 0.3 mo, P < 0.001) as well as statistically improved median survival time (13 mo vs 8 mo, P < 0.001). Both ERFA with stenting and PRFA with stenting groups demonstrated statistical superiority to biliary stenting alone (P < 0.001 and P = 0.004, respectively). However, when comparing ERFA to PRFA, pooled data demonstrated overall higher mean survival in the ERFA with stenting cohort as compared to PRFA with stent cohort (12.0 + 0.9 mo vs 8.1 + 2.1 mo, P < 0.0001). Data from two studies demonstrated a pooled median survival favoring ERFA with stenting as compared to PDT with stenting (11.3 mo vs 8.5 mo, P = 0.02). While further prospective, randomized studies are needed to assess efficacy of ERFA, our meta-analysis demonstrated that this technique offers endoscopists a reasonable palliative method by which to treat patients with unresectable CCA that results in longer survival as compared to biliary stenting alone, percutaneous radiofrequency ablation with biliary stenting, and PDT with biliary stenting as well as an acceptable adverse event profile based on available published data.

Nomogram for predicting the probability of permanent stoma in patients with acute obstructive colorectal cancer.

Acute obstructive colorectal cancer is a high-risk emergency among colorectal cancer (CRC). Approximately 20% of CRC patients are associated with a permanent stoma, which greatly affects the lifestyle of patients. This study aimed to investigate risk factors for predicting permanent stoma (PS) in patients with acute obstructive colorectal cancer. We retrospectively analyzed the clinical-pathological features of patients with acute obstructive colorectal cancer who underwent treatments from our hospital between January 2015 and December 2020. Univariate and multivariate logistic regression analyses were used to evaluate the risk factors for predicting PS chances of CRC patients using a nomogram method. Furthermore, the operating characteristic (ROC) curve and area under the ROC curve (AUC) were used to assess the discrimination power of the nomogram. Calibration plot was used to evaluate nomogram's calibration. A total of 98 patients with acute obstructive colorectal cancer were enrolled in this study, including 24 PS patients with permanent stoma and 74 non-PS patients. Multivariate analysis showed that age [odds ratio (OR): 1.068, 95% confidence interval (CI): 1.006 ~ 1.135, P = 0.032], carcinoembryonic antigen (CEA) [OR: 1.015, 95% CI: 1.003 ~ 1.028, P = 0.013], and surgical method [emergency group vs. stent group, OR: 14.066, 95% CI: 3.625 ~ 54.572, p < 0.001] were independent risk factors for PS. These risk factors were incorporated into a nomogram and showed that the AUC of the nomogram was 0.867 (95% CI: 0.782-0.951). The calibration plot got consistent with prediction for PS in the nomogram. Age, CEA, and surgical method were independent risk factors for PS in patients with acute obstructive colorectal cancer. Our nomogram has favorable predictive power for PS in CRC patients.

Do Biliary Stents Affect EUS-Guided Tissue Acquisition (EUS-TA) in Solid Pancreatic Lesions Determining Biliary Obstruction? A Literature Review with Meta-Analysis.

There is a paucity of evidence regarding whether biliary stents influence endoscopic ultrasound-guided tissue acquisition using either fine-needle biopsy (EUS-FNB) or fine-needle aspiration (EUS-FNA), among patients with head of pancreas (HOP) lesions. We aimed at assessing the diagnostic accuracy of endoscopic ultrasound-guided tissue sampling in patients with or without bile duct stents. A total of seven studies with 2458 patients were included. The main aim was to assess overall pooled diagnostic accuracy. A pairwise meta-analysis was performed using a random effects model. Outcomes were expressed as odds ratios (ORs) with 95% confidence intervals (CIs). We found that pooled accuracy was 85.4% (CI 78.8-91.9) and 88.1% (CI 83.3-92.9) in patients with and without stents, respectively. There was no statistically significant difference between the two (OR 0.74; p = 0.07). Furthermore, patients with metal stents demonstrated a significant difference (OR 0.54, 0.17-0.97; p = 0.05), which was not seen with plastic stents. EUS-FNB showed poorer diagnostic accuracy with concurrent biliary stenting (OR 0.64, 0.43-0.95; p = 0.03); however, the same was not observed with EUS-FNA. Compared to plastic stents, metal biliary stenting further impacted the diagnostic accuracy of EUS-guided tissue acquisition for pancreatic head lesions. There was no difference in the rate of procedure-related adverse events between the stent and no-stent groups.

The Infectious Complications of Biliary Decompression Prior to Pancreaticoduodenectomy in a Patient with Obstructive Jaundice

Background: The standard of therapy for benign diseases, periampullary and ampullary cancers is pancreaticoduodenectomy (PD). These patient subgroups frequently present with obstructive jaundice, which is associated with increased morbidity due to impaired immunity and nutrition. It is controversial whether PBD should be applied routinely prior to pancreaticoduodenectomy. Objective: The purpose of this study is to investigate infectious complications of biliary decompression prior to pancreaticoduodenectomy in a patient with obstructive jaundice. Methods: This single-center, cross-sectional study was done at BSMMU from April 2021 to March 2022. The study comprised 48 pancreaticoduodenectomy patients who met the criteria. Two groups formed. Group I had preoperative biliary drainage (n=24) while Group II did not (n=24). After written consent, all patient data was collected in a standardized form. SPSS version 23.0 ran statistical analysis. Unpaired t-test was used to evaluate mean SD quantitative variables. Chi-square test was conducted to see any association between qualitative observations and frequencies and percentages. P 0.05 was considered statistically significant in 95% confidence interval tests. Results: Overall infectious complications were not significant between two group (75%vs 41.7%; p=0.097). But SSI was higher in stent group (p=0.040). This stent group also observed higher positive bile culture 83.3% with significant polymicrobial growth (p=0.012). Commonly used antibiotics showed higher resistance to those biliary organisms; Cephalosporin (50 75%), Carbapenem (41.7%). There was also significant association between positive bile culture with SSI (p=0.048). Per- operative adhesion (p=0.001) and blood loss (p= 0.006) observed more in stent group. Although significant improvement of liver function observed following stenting. Conclusions: Increased risk of resistant polymicrobial bactibilia with strong association with SSI; preoperative biliary .......

COMMON BILE DUCT STONE EXPLORATION: T-TUBE OR BILIARY

The aim of the work: to reduce hospital length of stay and morbidity after stent placement compared with T-tube drainage. Reduce costs and increase patient satisfaction with biliary stenting Materials and Methods. The study involves 52 patients with choledocholithiasis who underwent LCBDE and decompression of the biliary system by either antegrade biliary stent or T-tube insertion. A 7 French biliary stent (9 “10 cm long) have been placed in 27 patients (group I), T-tube insertion have been used for 25 patients (group II). The length of hospital stay and complications were recorded. All transcystic explorations were excluded. Results. There were no significant differences between groups with respect to age, sex, comorbidities, number and size of CBD stones. Postoperative complications have been observed in 4 patients (16 %) in the T-tube group (one patient needed reoperation for dislocation of T-tube), and in 1 patient (3.7 %) in the biliary stent group (p &lt; 0.05). The mean postoperative hospital stay was 3.2 ± 1.2 days for group I, and 6.2 ± 1.7 days for group II (p &lt; 0.05).

Abstract Number ‐ 41: A Comparison of the Safety and Efficacy of Endovascular Techniques in Treating Basilar Tip Aneurysms

Introduction Basilar‐tip aneurysm (BTA) is the most common aneurysm found in the posterior fossa circulation, representing 5–8% of the total intracranial aneurysms. Endovascular techniques are first‐line for treatment of the vast majority of posterior circulation artery aneurysms because of their deep location and the high mortality and morbidity associated with open surgical clipping. Coil embolization (CE) is considered safer and more efficacious in the treatment of BTAs compared to open surgery but has increased rate of recanalization. Twoadjunctivemodifications of CE ‐balloon remodeling techniques(BRT) and stent‐assisted coiling (SAC) ‐ are availableto address the occlusion needs of BTAs of variable anatomies/morphologies, sizes, and rupture status.We aimed to compare the clinical utility, safety and efficacy of these adjuvant therapies for treating BTAs. Methods We conducted a retrospective review of the Barrow Neurological Institute (BNI) endovascular database from January 1996 through January 2019. Primary outcomes were obliteration as assessed by the modified Raymond Score (MRS), perioperative complications, recurrence, retreatment, and time to 1stretreatment. Secondary outcomes were stratification of the results based on rupture and wide‐neck status and the type of stent. Results 121 patients with an average follow‐up of 43.4 months were included. Ruptured aneurysms were more likely to be treated by CE vs. either adjuvant therapy (p&lt; 0.001), and SAC was the preferred treatment for larger aneurysms (p = 0.004). SAC had significantly worse obliteration (MRS of 2.09±0.94) vs. BRT (MRS of 1.82±0.91; p = 0.038) but was less likely to be retreated as compared to BRT (35.3%; p = 0.047). However, SAC had a shorter time to first retreatment 13.4±13.8 months as compared to the BRT (25.3±26.7 months) and CE (50.3±68.5 months; p = 0.04 and 0.006, respectively). Lastly, SAC had significantly lower recurrence of 31.8% and near‐significantly lower retreatment rate of 27.3% (p = 0.045, 0.058, respectively) as compared to CE (recurrence of 46.2% and retreatment of 34.6%). There was no significant difference in peri‐operative complications among the three groups. Conclusions CE and its adjuvant therapies have similar safety profile but pose variable efficacy in terms of obliteration, recurrence, retreatment, and durability over time. This study represents one of the largest data sets on endovascular adjuvant therapy of BTAs and has the potential to inform clinical decision making when considering CE with BRT vs. SAC for BTA of specific size and morphology.As future directions, outcomes specifically in the old vs. new stent groups and according to further stratification of the largest dimension of the BTA will need to be analyzed, and we will further interrogate any association between the co‐morbidities, such as smoking status and hypertension, with aneurysm rupture, largest dimension, and wide‐neck status.

Folded-Stent: Mikrovasküler Stentleme Tekniğini Geliştirmek İçin Üçüncü Nesil Yöntem

Objective: Although microsurgical vessel anastomoses have become a routine procedure today, they are still among the difficult techniques to apply. The most important step in the success of the technique is the clear presentation of the vessel lumen. In this study, we aimed to describe a new technique that will provide an easier anastomosis by keeping the lumen open during microvascular anastomoses.&#x0D; Methods: Four groups were formed using the chicken wing radial artery, which is an inanimate animal model. One of these was the control group who underwent standard microvascular repair. The second and third groups that followed were those in which two previously defined intravascular stenting techniques were applied. The fourth group was the Folded stent group that we just defined.&#x0D; Results: Anastomosis time was found to be significantly longer when compared to other groups in our newly defined technique. This time was an average of 3 minutes. No significant difference was observed in terms of the number of sutures used in anastomoses. No posterior wall suture complication was observed in any specimen.&#x0D; Conclusions: “Folded-Stent” technique provides a great advantage over other stenting techniques in terms of keeping the lumen open during the anastomosis and preventing the adhesion of the vessel walls. It is an advantageous technique that can be used in clinical practice, especially during venous repairs, to prevent posterior wall suturing of small caliber vessels.

Biodegradable biliary stents coated with mesenchymal stromal cells in a porcine choledochojejunostomy model

Background aimsRoux en y anastomosis is a preferred method of biliary reconstruction in liver transplantation that involves living donors or pediatric patients. However, biliary stricture is a frequent and serious complication, accounting for up to 40% of biliary complications in these patients. Previously, we demonstrated that extraluminal delivery of adipose-derived (AD) mesenchymal stromal cells (MSCs) decreased peri-biliary fibrosis and increased neo-angiogenesis in a porcine model of duct-to-duct biliary anastomosis. In this study, we used a porcine model of Roux en y anastomosis to evaluate the beneficial impact of a novel intraluminal MSC delivery system. MethodsNine animals were divided into three groups: no stent (group 1), bare stent (group 2) and stent coated with AD-MSCs (group 3). All animals underwent cholecystectomy with roux en y choledochojejunostomy. Two animals per group were followed for 4 weeks and one animal per group was followed for 8 weeks. Cholangiograms and blood were sampled at baseline and the end of study. Biliary tissue was collected and examined by Masson trichrome staining and immunohistochemical staining for MSC markers (CD34 and CD44) and for neo-angiogenesis (CD31). ResultsTwo of three animals in group 1 developed an anastomotic site stricture. No strictures were observed in the animals of group 2 or group 3. CD34 and CD44 staining showed that AD-MSCs engrafted successfully at the anastomotic site by intraluminal delivery (group 3). Furthermore, biliary tissue from group 3 showed significantly less fibrosis and increased angiogenesis compared with the other groups. ConclusionsIntraluminal delivery of AD-MSCs resulted in successful biliary engraftment of AD-MSCs as well as reduced peri-biliary fibrosis and increased neo-angiogenesis.

Development of novel biliary metal stent with coil-spring structure and its application in vivo swine biliary stricture model.

As of date, endoscopic biliary stenting with plastic stent (PS) and self-expandable metal stent (SEMS) have been widely used for the palliation of biliary tract strictures. However, these two stents have several limitations regarding the management of biliary strictures caused by intrahepatic and hilar cholangiocarcinoma. PS has short patency and also risks bile duct injury and bowel perforation. SEMS is difficult to revise when occluded by tumor overgrowth. To compensate for such shortcomings, we developed a novel biliary metal stent with coil-spring structure. The aim of this study was to investigate the feasibility and efficacy of the novel stent in a swine model. The biliary stricture model was prepared in six mini-pigs using endobiliary radiofrequency ablation. Conventional PS (n=2) and novel stents (n=4) were deployed endoscopically. Technical success was defined as successful stent placement and clinical success was defined as >50% reduction of serum bilirubin level. Adverse events, stent migration, and endoscopic removability for one month after stenting were also assessed. The biliary stricture was successfully created in all animals. The technical success rate was 100 %, and the clinical success rate was 50% in the PS group and 75% in the novel stent group. In the novel stent group, the median pre- and post-treatment serum bilirubin levels were 3.94 and 0.3 mg/dL. Stent migration occurred in two pigs and two stents were removed by endoscopy. There was no stent-related mortality. The newly designed biliary metal stent was feasible and effective in a swine biliary stricture model. Further studies are needed to verify the usefulness of the novel stent in the management of biliary strictures.

Right ventricular outflow tract stenting promotes pulmonary artery development in tetralogy of fallot.

Right ventricular outflow tract (RVOT) stenting seems to be suggested as a promising treatment option and an alternative to modified Blalock-Taussig shunt (mBTS) in the initial palliation of patients with Fallot-type lesions in recent years. This study sought to assess the effect of RVOT stenting on the growth of the pulmonary artery (PA) in patients with Tetralogy of Fallot (TOF). Retrospective review analyzing 5 patients with Fallot-type congenital heart disease with small pulmonary arteries who underwent palliative with RVOT stenting and 9 patients underwent modified Blalock-Taussig shunt within 9 years period. Differential left PA (LPA) and right PA (RPA) growth was measured by Cardiovascular Computed Tomography Angiography (CTA). RVOT stenting improved arterial oxygen saturation from median of 60% (interquartile range [IQR]: 37% to 79%) to 95% (87.5% to 97.5%) (p = 0.028). The LPA diameter Z-score improved from -2.843 (-3.51-2.037) to -0.78 (-2.3305-0.19) (p = 0.03), the RPA diameter Z-score improved from median -2.843 (-3.51-2.037) to -0.477 (-1.1145-0.459) (p = 0.002), the Mc Goon ratio increased from median 1 (0.8-1.105) to 1.32 (1.25-1.98) (p = 0.017). There were no procedural complications and all 5 patients have undergone final repair in the RVOT stent group. In the mBTS group, the LPA diameter Z-score improved from -1.494 (-2.242-0.6135) to -0.396 (-1.488-1.228) (p = 0.15), the RPA diameter Z-score improved from median -1.328 (-2.036-0.838) to 0.088 (-0.486-1.223) (p = 0.007), and there were 5 patients occur different complications and 4 patients was not attained the standards of final surgical repair. RVOT stenting, compared with mBTS, seems to better promote pulmonary artery growth, improve arterial oxygen saturations, and have less procedure complications in patients with TOF who being absolute contraindicated for primary repair due to high risks.

Retrieval of renal function after renal artery stenting improves event-free survival in a subgroup analysis of the Cardiovascular Outcomes in Renal Atherosclerotic Lesions trial

ObjectiveThe Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) trial, a multicenter randomized controlled trial with 947 patients, concluded that there was no benefit of renal artery stenting (RAS) over medical therapy. However, patients with chronic kidney disease (CKD) were not analyzed separately in the CORAL trial. CKD is a risk factor for cardiovascular and renal morbidity. We hypothesized that improved renal function after RAS would be associated with increased long-term survival and a lower risk of cardiovascular and renal events in patients with CKD. MethodsThis post hoc analysis of the CORAL trial included 842 patients with CKD stages 2 to 4 at baseline who were randomized to optimal medical therapy alone (OMT; n = 432) or RAS plus OMT (RAS + OMT; n = 410). Patients were categorized as responders or nonresponders based on the change in the estimated glomerular filtration rate (eGFR) from baseline to last follow-up (median, 3.6 years; interquartile range, 2.6-4.6 years). Responders were defined by a 20% or greater increase in eGFR from baseline; all others were designated as nonresponders. Event-free survival was defined as freedom from death and multiple cardiovascular and renal complications. Event-free survival was analyzed using the Kaplan-Meier method and log-rank test. Multivariable Cox proportional hazards regression analysis was used to identify independent predictors of event-free survival. ResultsThe RAS + OMT group had a higher proportion of patients with improved renal function (≥20% increase in eGFR over baseline), compared with the OMT group (25.6% vs 17.1%; P = .003). However, event-free survival was no different for the two cohorts (P = .18 by the log-rank test). Multivariable Cox proportional hazards regression analysis identified four variables that independently correlated with event-free survival for the stented cohort. Higher preoperative eGFR (hazard ratio, 0.98; 95% confidence interval [CI], 0.96-0.99; P = .002) and being a responder to stenting (hazard ratio, 0.49; 95% CI, 0.26-0.95; P = .033) increased event-free survival, whereas a history of congestive heart failure (hazard ratio, 2.52; 95% CI, 1.46-4.35; P < .001) and a higher preoperative systolic BP (hazard ratio, 1.02; 95% CI, 1.01-1.03; P = .002) decreased event-free survival. Within the stented group, 105 of 410 patients (25.6%) were responders. Event-free survival was superior for responders, compared with nonresponders (P = .009 by log-rank test). The only independent preoperative negative predictor of improved renal function after stenting was diabetes (odds ratio, 0.37; 95% CI, 0.16-0.84; P = .017), which decreased the probability of improved renal function after RAS + OMT. A subset of patients (23.4%) after RAS had worsened renal function, but OMT alone produced an equivalent incidence of worsened renal function. An increased urine albumin/creatinine ratio was an independent predictor of worsened renal function after RAS. ConclusionsCORAL participants who demonstrated improved kidney function after RAS + OMT demonstrated improved event-free survival. This finding reinforces the need for predictors of outcome to guide patient selection for RAS.

Szabo versus provisional stenting of bifurcation coronary lesions

Highlights. This article presents a comparative analysis of the results of PCI of bifurcation coronary lesions using the Szabo technique and provisional stenting in patients with chronic coronary artery disease.Background. Coronary bifurcation and ostial stenosis are difficult to treat and require precise stent positioning in order to prevent restenosis and thrombosis.Aim. To perform a comparative analysis of the outocmes of percutaneous coronary interventions (PCI) of coronary bifurcation lesions using the Szabo technique and provisional stenting in patients with chronic coronary artery disease.Methods. The retrospective single-center observational study included 791 patients. In accordance with the performed bifurcation PCI technique, the patients were divided into two groups: 42 patients in the Szabo group and 749 in the provisional stenting group. Propensity score matching was performed for endpoint analysis, as a result of which 42 patients were selected out of 749 patients in the provisional stenting group, comparable in baseline characteristics with 42 patients in the Szabo group. Study endpoints were cardiac death, myocardial infarction, and repeat revascularization. A composite endpoint (MACE) including all of the above was also evaluated.Results. The median follow-up in the provisional stenting and Szabo groups was 1.3 and 1.4 years, respectively. There were no significant differences between the groups in terms of mortality, myocardial infarction, repeated revascularization and composite endpoint (MACE 23.80% provisional stenting and 19.04% Szabo, p = 0.594).Conclusion. Thus, Szabo is technically simple and safe technique for stenting coronary bifurcation lesions in patients with chronic coronary artery disease, which is not inferior in terms of efficiency to provisional stenting.