Temporary Plastic Research Articles

THU369 A Rare Case Of IgG4-related Autoimmune Pancreatitis And Diabetes Mellitus

Abstract Disclosure: M. Zahid: None. J. Shakil: None. Introduction: IgG4 related disease (IgG4-RD) is a rare multiorgan inflammatory condition characterized by dense lymphoplasmacytic infiltrates, presence of IgG4+ plasma cells and fibrosis. Here we present a case of young male with painless jaundice and hyperglycemia diagnosed with IgG4 related autoimmune pancreatitis and DM. Clinical Case: 46-year-old male with no significant history presented to outpatient clinic for pruritis and dark-colored urine of 2-week onset. He reported 17-pounds weight loss in the preceding month. While undergoing outpatient workup, patient developed epigastric pain prompting visit to the hospital. On examination, patient was afebrile, tachycardiac, icteric and had epigastric tenderness. Labs revealed normal electrolytes and renal function. LFTs were significant for total protein 7.6 g/dl (n=6.3-8.3 g/dl), AST 77 U/L (n = 10-50 U/L), ALT 127 U/L (n = 5-50 U/L), alkaline phosphatase 458 U/L (n = 40-129 U/L) and direct bilirubin >10.0 (n = 0-0.3 mg/dl). Lipase was 99 U/L (n - 13-60 U/L), blood glucose was 292 mg/dl and A1C was 6.5% (n = 4.0-5.6%). US abdomen revealed diffuse gallbladder wall thickening with moderate sludge and intrahepatic and extrahepatic distal biliary obstruction and dilatation. MRCP showed common bile duct and intrahepatic biliary ductal dilation. Pancreas was diffusely irregular with areas of hemorrhagic pancreatitis. ERCP showed dilatation of upper and middle third of main bile duct, left and right hepatic ducts and all intrahepatic branches with a stricture in distal bile duct. Biliary sphincterotomy and placement of temporary plastic biliary stent was performed and ampullary biopsies were taken. IgG4 level was checked due to suspicion for IgG4-RD and was 293 mg/dl (n: 1-123 mg/dl). Pathology revealed mucosa with epithelial reactive changes. CD138 stain showed several mature plasma cells within the inflammatory infiltrate. In addition, immunostain for IgG4 shows several IgG4 positive plasma cells forming small clusters confirming diagnosis of IgG4-RD. Post procedure, his abdominal pain and LFTs started improving. Patient was started on prednisone for IgG4-RD and insulin for persistent hyperglycemia. His prednisone dose was later tapered after starting methotrexate. Patient’s most recent LFTs have normalized except mildly elevated ALT and A1C improved to 6.2%. Conclusion: Autoimmune pancreatitis and cholangiopathy are the pancreatobiliary manifestation of IgG4-RD and most often present as painless jaundice mimicking pancreatic cancer. Endocrine insufficiency usually manifests as diabetes mellitus/pre-diabetes and may also lead to autoimmune hypophysitis and Reidel’s fibrosis. Other organ systems that may also get involved include lacrimal and salivary glands, lungs, kidneys, nervous system, and lymphatic/vascular system. Early recognition and ongoing surveillance are key to appropriate management of this condition. Presentation: Thursday, June 15, 2023

Successful Endoscopic Treatment of Difficult Common Bile Duct Stones Using Various Interventional Techniques: A Case Report

Clearance of a difficult biliary stone can be obtained using various interventional techniques such as endoscopic sphincterotomy followed by endoscopic papillary large balloon dilation, mechanical lithotripsy, peroral cholangioscopy-assisted intraductal electrohydraulic/laser lithotripsy, temporary plastic stent insertion, percutaneous transhepatic cholangioscopy-guided lithotripsy, and extracorporeal shock wave lithotripsy. We hereby describe the successful endoscopic treatment using various currently available interventional techniques in a case with multiple difficult common bile duct stones. Furthermore, we discuss the countermeasures to overcome the hurdles of each procedure.

Переживание безопасности и темпоральность личности

The article with the involvement of empirical material examines the temporal features of a person experiencing and not experiencing safety. Differences in relation to time, temporal orientation and time functions in subjects are revealed. The respondents in the study were 250 people (139 girls and 111 boys) aged 18 to 22 years. The surveyed are students of Ugra State University and Kurgan State University of full-time education. The survey used the author's set of methods: "Scale of subjective attitude to time," the questionnaire "Subjective assessment of temporal orientation," as well as the questionnaire "Temporal characteristics of personal danger-safety." It has been found that the dominant type of relation to time in the group of subjects experiencing safety is temporary plasticity, while in those not experiencing safety it is temporary dependence. It was revealed that time performs a mobilization function, for subjects experiencing safety, while for those examined not experiencing safety, the "overwhelming" function of time is the leading one. In the temporal orientation of subjects experiencing security, the resource orientation towards the "present" and "future" is expressed, and in the group of subjects not experiencing security, these modalities are of the nature of psycho-modern fixation, thereby determining the destructive nature of their temporal orientation. It has been shown that temporal characteristics of personality - relation to time, its functions and temporal orientation can act as indicators of safety experiences. Thus, the assessment of temporal personality features can be used to diagnose the experience of safety (danger).

Aquatic plants entrap different size of plastics in indoor flume experiments

Plastics accumulate in the environment affecting biota and ecosystems. Although rivers are vectors of land-based plastics to the sea, macroplastics and microplastics in rivers are recently studied. Most studies focused on floating plastic transport to the sea through rivers considering only abiotic hydromorphological factors. In this view, among biotic factors, vegetation has recently been found to entrap plastics. Indeed, the role of vegetation is pivotal in affecting riverine plastic transport. While marine vegetation blocking plastics has been studied, research in freshwater ecosystems is neglected. Since hydrological factors have a pivotal role in riverine plastic transport and few is known on plant entrapment, the interaction between hydrological variables and plastic entrapment by vegetation has not yet been investigated. Given that the composition, transport, and fate of “submerged” plastics in the water column are neglected, we aimed at investigating the behaviour of plants in entrapping plastics within a specific laboratory flume tank. Specifically, we assessed whether (i) aquatic plants block different plastic sizes within the water column and (ii) different factors (e.g. water level, density of plants) affect plastic entrapment. Our results showed that, according to plant density, the higher the plant density the higher the entrapment of plastics by plants - independently of plastic size. Considering the water level, macro-, meso-, and microplastics were trapped similarly. Moreover, Potamogeton crispus blocked fewer microplastics compared with Myriophyllum spicatum. Our results might have impact as plants acted as temporary plastic trappers and can be used as tools for mitigating plastic pollution. Future research might investigate if this laboratory approach can be applied in field for recollecting plastics and consequently mitigating the problem. In conclusion, good management of plants in watercourses, canals, and rivers should be ideal for enhancing river functionality and ecosystem services for human well-being (i.e. the plastic entrapment service by plants).

S1922 A Twisted Plot: Pancreas Divisum With Right-Sided Pancreaticopleural Fistula

Introduction: We report on a 53-year-old male with a past medical history significant for chronic pancreatitis who presented with a right-sided pleural effusion secondary to pancreaticopleural fistula with pancreatic divisum. Pleural effusion secondary to pancreaticopleural fistula (PPF) is a rare complication of acute or chronic pancreatitis and usually presents with a left-sided pleural effusion. This case also highlights the difficulty and significant delay in diagnosing pancreas divisum on cross-sectional imaging. Case Description/Methods: A 53-year-old male with a medical history significant for chronic pancreatitis complicated by pancreatic ascites, walled-off necrosis, splenic and portal vein thrombosis, alcoholic gastritis, and polysubstance use presented with five days of dyspnea with new and worsening oxygen requirements. Chest x-ray showed a new moderate right-sided pleural effusion. Pleural fluid analysis revealed elevated lipase of >3,000 U/L and amylase of 21,008 U/L concerning for a pancreaticopleural fistula. MRI of pancreas showed a disconnected duct at the tail of the pancreas with a fistula extending into the mediastinum and peritoneum. During ERCP a bulging minor papilla was noted. After failed initial attempts at cannulating ventral duct, minor papilla was approached and dorsal duct was cannulated. Pancreatogram revealed a complete pancreatic divisum with a leak in the tail of the pancreas. A temporary plastic stent was placed in the dorsal duct after minor papilla sphincterotomy. The patient's symptoms resolved and he was discharged home with outpatient follow-up (Figure). Discussion: PPF is a rare complication of pancreatitis that typically presents as large, recurrent, left-sided pleural effusion often refractory to thoracentesis management. Transpapillary stent placement in the pancreatic duct is widely used in the management of PPF. Our case shows a rare right-sided presentation of PPF in the setting of a newly diagnosed pancreas divisum missed on numerous previous cross-sectional imaging. High clinical suspicion of underlying divisum raised by endoscopic and imaging findings led to successful endoscopic management of this complex case.Figure 1.: MRCP Pancreas showing pancreas divisum and disconnected duct.

S1701 Bile Leak: A Rare Complication of Percutaneous Liver Biopsy

Introduction: Percutaneous liver biopsy is a cornerstone in diagnosing various hepatobiliary disorders. It is generally a safe procedure. Bile leak is a very rare complication, with rates less than 0.001%. Case Description/Methods: A 79-year-old woman presented to the emergency department with severe right upper quadrant abdominal pain along with nausea and vomiting after undergoing an ultrasound-guided percutaneous liver biopsy for elevated liver enzymes. On examination, right upper quadrant tenderness was appreciated. Computed tomography (CT) and Magnetic resonance imaging (MRI) of the abdomen were suggestive of blood products within the gallbladder. She underwent Endoscopic retrograde cholangiopancreatography (ERCP) for increased bilirubin (Table). On Fluoroscopy, she was found to have a bile leak at the level of the common hepatic duct (Figure). A temporary plastic biliary stent was placed into the common bile duct (CBD). Discussion: There are guidelines by the American Association for the Study of Liver and the Society of Interventional Radiology to prevent complications after percutaneous needle biopsies and liver biopsies. Utilizing ultrasound can help avoid injury to the gall bladder and large bile ducts. A biopsy of at least 2-3 cm length and 16-gauge caliber is considered sufficient. Patients should be closely observed for at least 2-4 hours after the procedure. Keeping a low threshold for prompt evaluation with appropriate imaging modalities and timely intervention can help overcome this challenge and reduce morbidity and mortality.Figure 1.: Fluoroscopy demonstrates extravasation of contrast at the level of the common hepatic duct, suggestive of bile leak Table 1. - Trend of total bilirubin through the hospital course. Notice the 50% decrease after biliary stent placement Total Bilirubin (mg/dL) 0.8 3.6 6.2 6.7 7.4 3.1 2.7 2.2 0.9

Management of difficult bile duct stones with temporary plastic stent and ursodeoxycholic acid treatment: 5 years of experience

Aim: The aim of the study was to investigate the effect of temporary plastic stenting and ursodeoxycholic acid (UDCA) treatment on difficult choledochal stones that cannot be removed by basic ERCP techniques in patients who applied to our clinic with occlusion and underwent endoscopic retrograde cholangiopancreatography (ERCP).
 Material and Method: Patients were scanned retrospectively using the hospital database. Patients who underwent ERCP due to malignancy, biliary tract injury and benign strictures were excluded from the study. 61 patients who were not successful with basic ERCP techniques such as endoscopic sphincterotomy (EST) and mechanical lithotripsy (ML) were included in the study. 750 mg/day UDCA was given to the patients for three months and plastic stent was applied. After the treatment, ERCP was tried again.
 Results: Among the patients who underwent stent+UDCA, three (4.9%) patients had perioperative bleeding, one (1.6%) patient had peroperative perforation, four (6.6%) patients had postoperative pancreatitis, and one (1.6%) patient had mortality. The mean hospital stay was 1.96±2.1 days. Post-procedure total bilirubin and direct bilirubin values were observed to be lower than before the procedure (respectively, p

Endoscopic management of difficult common bile duct stones.

Common bile duct stones are a very frequent problem in the western world and endoscopic stone clearance is the method of choice for treatment. Despite its common use, endoscopic clearance of common bile duct stones is not always trivial especially in cases involving large or multiple stones. A literature review regarding different endoscopic techniques was performed for this article and a recommended therapeutic algorithm developed based on the guidelines of the European Society of Gastrointestinal Endoscopy and the German Gastroenterological Society. This review gives an overview of currently applied endoscopic techniques, their success and complication rates as well as alternative methods used for cases involving anatomic anomalies. The purpose of this review is to recommend a therapeutic algorithm for the treatment of difficult common bile duct stones (DCBDS). For the treatment of DCBDS, combined sphincterotomy and endoscopic large balloon dilation should be first choice. Mechanical lithotripsy and cholangioscopy-guided lithotripsy are close alternatives with nearly equal clearance rates and should be used if accessible. The insertion of a temporary plastic stent is a good choice to gain time to explore further treatment options. Enteroscopy-based endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangioscopy or endoscopic ultrasound-guided hepaticogastrostomy and stone treatment, while good alternatives for select cases involving anatomic anomalies, should be performed at specialized units.

FEATURES OF MANUFACTURE OF ADVANCED PROVISIONAL BRIDGE-BASED PROSTHESES

Abstract. The relevance of the topic is related to the need to improve methods of preparation of dentitions for orthopedic treatment, taking into account the defects of dentitions in patients with reduced occlusion height, taking into account the condition of the masticatory muscles and temporary use of plastic dentures, which provide gradual lifting of occlusion to normalize the masticatory group muscles and reorganization of myostatic reflexes.
 The aim of the research. Improving the effectiveness of preparation for orthopedic treatment of patients with partial tooth loss, with reduced occlusion height, by improving the design of a temporary bridge-based prosthesis.
 Materials and methods of research. We examined, treated and conducted clinical observation of 93 patients, who were divided into three groups according to the height of the reduction in occlusion, to achieve this goal and solve problems during the dissertation. Group 1 consisted of 32 patients with included dentition defects with reduced occlusion height up to 2 mm (n=32), group 2 - patients with included dentition defects with reduced occlusion height up to 2-4 mm (n=31), group 3 - these are patients with included dentition defects with reduced occlusion height up to 4-6 mm (n=30). All patients of the main groups belonged to the second and third age groups according to the WHO, aged 35-55 years. The control group (n=30) are young people who belonged to the 1st age group according to the WHO with intact dentition, without concomitant somatic and dental pathology, were admitted in one visit. Also, 123 fiberglass-reinforced plastic prostheses were made.
 Research results. When drawing up a plan for orthopedic treatment of patients with reduced occlusion height, we took into account possible complications, which are characterized by chipping of the facing material, pathological changes in the temporomandibular joint and masticatory muscle group. We have improved the method of manufacturing non-removable temporary plastic orthopedic constructions by reinforcing with fiberglass tapes and beams, to prevent them and gradually raise the bite.
 Expanded data on the dynamics of changes in myostatic reflexes and the effectiveness of the use of fixed orthopedic constructions, depending on the pathological process, the timing of adaptation of the masticatory muscle group to orthopedic constructions, according to the degree of reduction in occlusion height. The absence of complaints of breakage and other technical defects of the proposed temporary orthopedic constructions in 100% of cases, successfully allows to use it in the clinic of orthopedic dentistry.
 A new method of preparing patients for permanent orthopedic treatment by combined reinforcement of temporary non-removable bridge constructions with fiberglass tapes and beams is proposed, which differ in that after preliminary modeling of the frame of the bridge constructions, the technology of double reinforcement, model two support platforms with a step-like transition between them, in which fiberglass tapes and beams are fitted with dental tweezers, after which they are polymerized by the generally accepted method with a photopolymer lamp. Complete the modeling of the constructions and polymerize the prosthesis in the pneumopolymerizer with subsequent grinding and polymerize the prosthesis.
 Conclusion. The results of the research revealed the high efficiency of the improved method of manufacturing non-removable makeshift plastic of orthopedic constructions.

ORTHOPEDIC RESTORATION OF PARTIAL TOOTH LOSS AND WAYS OF ITS IMPROVEMENT

The increase in the prevalence and intensity of dental diseases in modern conditions, such as caries and its complications, non-carious lesions and pathological abrasion of dental hard tissues and periodontal diseases, leads to partial tooth loss and persistent pathological morpho-functional changes of the dentoalveolar system.
 Partial tooth loss is accompanied by changes in almost all areas of the dentoalveolar system and leads to a number of complications, including deformations of the dentition. At the same time, changes in the neuromuscular system, dysfunction of the temporomandibular joints (TMJ), aesthetic, phonetic and functional disorders are often involved in clinical symptoms. Pathological morphological changes significantly complicate orthopedic treatment, and often make it impossible without the use of a set of special preparatory measures.
 To restore the integrity of the dentition and the functional efficiency of the masticatory apparatus, various designs of dentures are used, which are divided into fixed and removable according to the terms of fixation, and their choice is determined by the list of indications and contraindications for manufacturing.
 It is known that non-removable structures are much more widely used as compared to removable prostheses, as they have a number of advantages: restoration of masticatory efficiency by 95-100%, high aesthetics and accuracy, good fixation and quick adaptation to them. The main condition of orthopedic treatment with bridges is the presence of defects limited by teeth. They are used in case of a defect of the dentition, which consists in the loss of no more than 3 lateral teeth and 4 teeth in the frontal jaw.
 The sizes of dental bridges do not go beyond the dentition and they transfer the masticatory load to the jawbone through the periodontium, i.e., naturally. Because of this, they are considered more physiological than other prostheses. Bridge prostheses virtually do not disrupt the speech, temperature, tactile and taste sensitivity.
 Orthopedic treatment of dentition defects is also carried out with the help of removable structures, which include removable bridges, arches and partial laminar dentures. The advantage of removable dentures is their high hygiene, but the problems include proper fixation, long-term adaptation, aesthetic requirements and full recovery of masticatory efficiency.
 The aim of the research is to improve the quality of orthopedic care for patients with defects of the dentition with the help of bugel prostheses on clasps by introducing an original method of their manufacture.
 Material and methods of experimental studies. We made 138 solid bugel prostheses (84 – the upper jaw, and 54 – the lower jaw), 48 bridge prostheses (39 metal-ceramic, 9 with photopolymer facing). We observed 95 patients aged from 23 to 74 years (52 men, 53 women) during the period of 5 years. In all patients, the defects of the dentition were replaced with solid bugel prostheses on the clasps, according to our original method:
 Upon receipt of the impression for the metal-ceramic non-removable structure with a clasp, the previously made temporary plastic crowns were fixed on the prepared teeth, and then the impression was obtained with the impression spoon together with the temporary crowns and removed from the oral cavity. The working model was cast on the obtained imprint.
 The proposed method makes it possible to simultaneously obtain an impression on the basis of which a working model is made for the manufacture of both fixed and removable parts of the orthopedic structure, which avoids the repetition of clinical and technical stages of prostheses manufacture, reduce their number, improve the accuracy of connecting removable and non-removable structures, and saves materials and time for doctor and patient.

Plastic wrap combined with alcohol wiping is an effective method of preventing bacterial colonization on mobile phones.

Introduction:Using mobile phones for communication in emergency departments is a common practice; however, several studies have demonstrated that they may act as vectors for bacteria and viruses. This study evaluated the effectiveness of plastic wrapping in decreasing bacterial contamination on mobile phone surfaces.Method:We used culture dishes and a luminometer to detect bacterial colonies and contamination on the phone surfaces.Result:Our experiment showed that bacterial colonies exist on mobile phones before and after work. We found that wiping with 75% alcohol sanitizers effectively reduces the number of colonies on either a mobile phone or a temporary plastic covering. In addition, we found that bacterial colonies do not contaminate or adhere to plastic wrap any easier than to mobile phones.Conclusion:These results demonstrated the effectiveness of plastic wrap for protecting mobile phone surfaces against bacterial colonization. In addition, applying a layer of plastic wrap protects the phone from potential damage due to the alcohol.

Performance analysis of portable HEPA filters and temporary plastic anterooms on the spread of surrogate coronavirus

The outbreak of COVID-19, and its current resurgence in the United States has resulted in a shortage of isolation rooms within many U.S. hospitals admitting COVID-19-positive cases. As a result, hospital systems, especially those at an epicenter of this outbreak, have initiated task forces to identify and implement various approaches to increase their isolation capacities. This paper describes an innovative temporary anteroom in addition to a portable air purifier unit to turn a general patient room into an isolation space. Using an aerosolization system with a surrogate oil-based substance, we evaluated the effectiveness of the temporary plastic anteroom and the portable air purifier unit. Moreover, the optimal location of the portable unit, as well as the effect of negative pressurization and door opening on the containment of surrogate aerosols were assessed. Results suggested that the temporary anteroom alone could prevent the migration of nearly 98% of the surrogate aerosols into the adjacent corridor. Also, it was shown that the best location of a single portable air purifier unit is inside the isolation room and near the patient's bed. The outcome of this paper can be widely used by hospital facilities managers when attempting to retrofit a general patient room into an airborne infection isolation room.

Structure formation of a temporarily plasticized matrix of polymer composite materials with adjustable deformability for transformable structures

It is established that with the selected type and composition of the amino-epoxy copolymer, which is equilibrium swollen in the anhydride-epoxy temporary plasticizer, the decisive role in ensuring the initial elasticity and final deformation heat resistance of such systems plays the formation of the initial polymer network of the primary polymer, which, when combined with a temporary modifier, provides of a minimum low T g . The additional formation of the network structure of the primary polymer and the network interpenetrating with it, which is formed during the curing of the temporary plasticizer, provides the required T g of the cured composition as a whole, proportional to the mass fraction of components and the density of the networks. The processes of macrophase separation during curing of a temporary plasticizer and, accordingly, the regulation of the phase morphology of the cured compositions are limited by the formed network of the initial polymer.

Experimental Biointegration of a Titanium Implant in Delayed Mandibular Reconstruction.

Background: Mandibular reconstruction, after extensive resection of the mandible for the treatment of oral cancer, is a well-known procedure, however, relatively little is known about bone integration into the titanium implant after reconstruction with a temporary plastic implant. The main goal of this experimental study was to study the process of osseous integration into the titanium implant in an in vivo experiment following prior mandibular reconstruction with a temporary plastic implant. Materials and Methods: Four ewes initially underwent a partial one-sided resection of the mandible, with the formation of an approximately 3 × 1 cm defect. All of the subjects received reconstruction with an implantation of a plastic plate (3 cm). The plastic plate was removed and replaced by a titanium implant at 1, 3, 6, and 12 months, accordingly. Both plastic and titanium implants were made via 3D-printing technology and personalized modeling. A total of 6 months after titanium implantation, a histological evaluation of biointegration was performed. Results: All surgeries were uncomplicated. The integration of osseous tissue into the titanium implant was seen in all cases. Histologically, each case showed variable integration of dense fibrotic tissue with fibroblasts and non-mature bone tissue with a definitive layer of bone matrix with many osteoblasts on the periphery. The prior implantation of the plastic plate did not interfere with bone integration into the titanium implant. Conclusion: Preliminary results demonstrated that a temporary plastic implant for mandibular reconstruction does not interfere with the consequent osseous biointegration of a permanent titanium implant. This shows that temporary reconstruction is a safe solution when delayed mandibular reconstruction is required due to disease severity.

Gastric access temporary for endoscopy (GATE): a proposed algorithm for EUS-directed transgastric ERCP in gastric bypass patients.

Performing endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y gastric bypass (RYGB) anatomy is technically challenging. Device-assisted enteroscopy and laparoscopic-assisted methods suffer from high failure rates and/or post-procedural complications. A novel endoscopic technique termed EUS-Directed Transgastric ERCP (EDGE) or Gastric Access Temporary for Endoscopy (GATE) has recently emerged, demonstrating excellent technical and therapeutic success. The technique involves endoscopic ultrasound-guided deployment of a lumen-apposing metal stent (LAMS) to gain access into the remnant stomach to facilitate standard ERCP. In this case series, we describe our center's experience and unique approach with the GATE procedure and discuss several key strategies and differences. Patients underwent the GATE procedure via a novel algorithmic approach. Key information on procedural details, technical and clinical success, follow-up, and adverse events was prospectively collected and retrospectively reviewed. 10 patients underwent the GATE procedure from May 2017 to March 2018. Technical and clinical success were both 100%. Gastric and jejunal access points for LAMS deployment were 30% and 70%, respectively. Total procedure time per patient, including LAMS deployment, ERCP, and all follow-up procedures, averaged 2.37 ± 0.63h. 2 out of 10 patients (20%) had adverse events that were resolved either intra-procedurally or after repeat endoscopy with no long-term complications and none requiring surgery. For patients with complete follow-up (n = 7), access tract closure rate was 100% with the aid of a temporary plastic double pigtail stent to facilitate closure. GATE appears to be a safe and effective procedure and may be considered the preferred approach to ERCP in patients with RYGB anatomy at centers with LAMS experience. The procedure offers more definitive and higher range of ERCP interventions compared to traditional methods and is associated with fewer adverse events. Improvements in strategies and methods with the GATE technique may reduce risks and improve outcomes.

Sa1361 CHOLANGIOSCOPY-GUIDED HOLMIUM LASER LITHOTRIPSY IN THE TREATMENT OF DIFFICULT BILE DUCT STONES- A SINGLE CENTER EXPERIENCE

Using standard techniques, the treatment of bile duct stones is highly effective in 85-90% of cases. In 5-15% the stones are classified as “difficult” due to their size, location, form, calcification or altered anatomy. For these situations alternative treatment options are needed. Cholangioscopy- guided laser- or electrohydraulic lithotripsy increases the success rate of the bile duct stones treatment up to 100%. To evaluate the efficacy, safety and cost- effectiveness of the cholangioscopy guided laser lithotripsy for the treatment of difficult bile duct stones in the context of complications, price and mean procedure time. Data was collected retrospectively from January 2016 to September 2017. All the patients had previous single-session ERCP, sphincterotomy with or without large balloon dilation and plastic stenting performed and bile duct stones were characterized as “difficult” after attempts for extraction using standard techniques or after detection of anatomical abnormalities of the biliary system /strictures/. Patients were scheduled for cholangioscopy with the SpyGlass DS system (Boston Scientific, Marlborough, MA, USA). A 200 μm single use laser fiber (Cook Medical, Bloomington, IN, USA) was positioned close to the stone and lithotripsy was performed until complete fragmentation has been achieved (Settings- 1,2 mJ, 8Hz). The procedure was followed by balloon- or basket extraction of fragments. CBD clearance was confirmed by cholangioscopy. Further interventions were rescheduled if needed. For the period a total of 16 cholangioscopy- guided holmium laser lithotripsies were performed in 14 patients. 2 complications were documented- hemobilia caused discontinuation of the procedure in a patient with essential thrombocitopaenia and a case of mild cholangitis treated with i.v. antibiotic for 5 days. Nasobiliary drainage was left for 24 hours in 2 patients, 2 patients received temporary plastic stents for cholangitis- profilaxis due to residual debris . No serious adverse events requiring surgery, blood transfusions or ICU admission were noted. Cholangioscopy guided Holmium laser lithotripsy is a safe and effective option to treat difficult bile duct stones. The early implementation avoids multiple ERCP- sessions, surgery and related complications in patients, unsuitable for standard endoscopic treatment. Carefull patient selection is needed in relation with the cost- effectiveness and procedure duration.Table 1ResultsNumber of patients14Impacted CBD stones6/14 (42,8%)CBD stones8/14 (57%)Stones in the common hepatic duct2/14 (14,2%)Intrahepatic stones3/14 (21,4%)Stones in the cystic duct1/14 (7,1%)Size of the stones10-35 mmNumber of sessions until complete clearance1,14Duration of the procedure90-180 min.Complications2/14 (14,2%) Open table in a new tab

Symptomatic benign distal biliary stricture in the setting of anomalous pancreaticobiliary junction treated with metal biliary and temporary plastic pancreatic stents

Symptomatic benign distal biliary stricture in the setting of anomalous pancreaticobiliary junction treated with metal biliary and temporary plastic pancreatic stents

Intraductal Fenestration of Biliary Metal Stents Using Argon Plasma to Facilitate Bilateral Hilar Stenting

Background: When placed across the biliary confluence, uncovered self-expanding metal stents (SEMS) may impede access to the contralateral intrahepatic ducts. In particular it is difficult to place additional plastic or metal stents across multiple adjacent cells of a hilar SEMS. Argon plasma has been used to trim biliary SEMS. However, the use of argon plasma for intraductal fenestration of biliary metal stents has not been described. Case report: A 38-year-old man with hilar cholanogiocarcinoma presented with cholangitis and right lobe liver abscesses. He had been previously treated with placement of multiple closed-cell, uncovered SEMS extending from duodenum to left hepatic duct. A percutaneous transhepatic catheter was placed into an abscess cavity, which communicated with right hepatic ducts. Subsequently a percutaneous transhepatic guidewire was advanced through the hilar SEMS interstices and into the duodenum. During ERCP a temporary plastic stent was placed into the left main duct for venting of argon gas. The percutaneous guidewire was then grasped with a snare and brought out via the mouth. Choledochoscopy was then performed using a pediatric gastroscope which was advanced over the guidewire into the existing SEMS up to the level of the hilum. Metal struts of the embedded SEMS were seen crisscrossing over the right duct orifice. The visible SEMS wires were fenestrated using a pediatric argon plasma coagulation probe at power of 80 W and flow 0.3 L/min, and further unwoven with a pediatric biopsy forceps. Argon gas vented from the percutaneous biliary sheath as well as the left hepatic duct stent. Subsequently plastic stents were placed via a duodenoscope into 4 separate right intrahepatic ducts, each of which was accessed across adjacent interstices of the SEMS. The patient had rapid clinical improvement and a follow-up computed tomography at 4 weeks showed resolution of liver abscesses. Conclusion: Fenestration of hilar biliary SEMS using argon plasma under direct endoscopic visualization can facilitate bilateral hilar stent placement in patients with complex malignant obstruction of the central intrahepatic ducts. Argon plasma has been used to trim biliary and rectal SEMS. The use of argon plasma for endoscopic fenestration of duodenal stents to facilitate ERCP has also been reported. Our case extends the application of this technique by describing intraductal fenestration of an indwelling biliary SEMS to accomplish bilateral hilar stenting.

Biliary stenting in difficult common bile duct stones: a single tertiary center experience.

We aimed to examine the effect of plastic biliary stenting in the treatment of common bile duct (CBD) stones. The data of 13,034 patients in our unit who had endoscopic retrograde cholangiopancreatography (ERCP) between 2008 and 2015 were scanned retrospectively. A biliary stent was placed in 61 of 74 patients. While the plastic biliary stent was placed in patients, the mean stone size after the 1st ERCP was 20 mm and the bile duct size was 13 mm. At the time of the 2nd ERCP conducted approximately 73.9 days later, the mean stone size was found to be 15 mm and the bile duct size was 12 mm. With recurrent ERCPs, the CBD stone was successfully removed in 53 patients but could not be removed in 8 patients. Among the 53 successful cases, 29 removals were successful in the 2nd ERCP session, 16 were successful in the 3rd session, 2 were successful in the 4th session, 1 was successful in the 5th session, 4 were successful in the 6th session, and 1 was successful in the 7th session. For CBD stones that cannot be removed by standard methods, temporary plastic stenting is an alternative method.

Effect of the dimethylsilyloxy co-monomer “D” on the chemistry of polysiloxane pyrolysis to SiOC

The effect of the dimethylsilyloxy co-monomer “D” on the chemistry of polysiloxane pyrolysis to silicon oxycarbide (SiOC) glass was studied with the aim of its optimization for the preparation of refractory composites with ceramic fibers. Reasonably small weight losses (shrinkage), but also some temporary plasticity of the material during its pyrolysis was sought. The pyrolysis chemistry was varied by preparing precursors from methyltriethoxysilane (T; main monomer) and dimethyldiethoxysilane (D; co-monomer) in different ratios, but also by using an alternative composition based on tetraethoxysilane (Q) and D. Pyrolysis temperatures between 300 and 1000°C were studied, and the escaping gases – polar, as well as non-polar – were analysed by means of chromatography/mass spectrometry. It was demonstrated, that the co-monomer D, which undergoes thermal elimination and subsequent reactions with the siloxane skeleton, seems to be responsible for the generally useful “micro-creep” ability of the pyrolyzing material. At higher D contents, where the pyrolysis weight losses strongly increase, the pyrolysis gases were shown to contain also polycyclic oligomers, which consist not only of D, but of the branching T or Q “main” monomers as well. The SiO/SiC exchange reactions of escaping D with the skeleton were found to be highly efficient not only in T/D, but also in Q/D polysiloxanes. It was further found, that the SiOC products after completed pyrolysis at 1000°C still can release gases detectable by GC/MS upon repeated heating, although no significant weight losses are observed: this indicates the presence of small amounts of pyrolysable sediments in micro- and nano-pores of the SiOC glass.