Time Of Stent Removal Research Articles

The Temporary Placement of Covered Self-Expandable Metal Stents to Seal Various Gastrointestinal Leaks after Surgery

Gastrointestinal leakage is one of the most serious post surgical complications and is a major source of mortality and morbidity. The insertion of a covered self-expandable metal stent could be a treatment option in selected cases. However, it is unclear how long the stent should be retained to achieve complete sealing, and membrane-covered stents have the problem of a high migration rate. We observed four cases of postsurgical leakage following the primary closure of a duodenal perforation, esophagojejunostomy, and esophagogastrostomy, each of which was successfully managed by the temporary placement of covered stents. In all cases, the optimal time of stent removal could be estimated by the markedly decreased amount of drainage, the lack of leakage observed on radiocontrast images, and the endoscopic findings. In this case series, all of the stents could be removed within 7 weeks. For those cases with a high risk of migration, stents with temporary fixations to earlobes and/or partially uncovered proximal flanges were used. These results suggest that the application of a covered stent could be a treatment option for various gastrointestinal leaks after surgery, particularly when the defect cannot be sealed by conservative care and the leakage has good external drainage.

Tunica vaginalis flap cover in repair of recurrent proximal urethrocutaneous fistula: A final solution

The objective of this study was to assess the significance of tunica vaginalis flap cover in cases of recurrent proximal penile fistula. This retrospective study included complicated cases of proximal penile hypospadias with recurrent fistula. Recurrent fistula was defined as fistula after at least two previous attempts of closure. Group 1 included cases with tunica vaginalis flap and Group 2 included cases with local flap. Outcome was assessed at day 10 after stent removal and at first follow-up. Fistula closure was considered successful in case with no leak. Out of 39 cases of recurrent fistulas, 20 cases in Group 1 and 18 cases in Group 2 formed the study group. The mean age at fistula repair was 7.2 ± 0.9 years (range: 2.1-12 years) and 7.1 ± 0.7 years (range: 2.3-12 years) in Group 1 and 2 respectively. Leak at the time of stent removal was present in 1/20 (5%) and 3/18 (16.67%) cases in Group 1 and 2 respectively (P = 0.04). Leak at the time of first follow-up was present in 2/20 (10%) and 4/18 (22.22%) cases in Group 1 and 2 respectively (P = 0.03). Complete disruption of fistula closure was present in 1/20 (5%) and 2/18 (11.11%) cases in Group 1 and Group 2 respectively (P = 0.1). The overall success rate in Group 1 and 2 was 16/20 (80%) and 9/18 (50%) respectively (P = 0.01). Tunica vaginalis flap reinforcement is a viable and reliable option. With proper use cases of recurrent fistula can be managed successfully.

Timing of silicone stent removal in patients with post-tuberculosis bronchial stenosis

CONTEXT:In patients with post-tuberculosis bronchial stenosis (PTBS), the severity of bronchial stenosis affects the restenosis rate after the silicone stent is removed. In PTBS patients with incomplete bronchial obstruction, who had a favorable prognosis, the timing of stent removal to ensure airway patency is not clear.AIMS:We evaluated the time for silicone stent removal in patients with incomplete PTBS.SETTINGS AND DESIGN:A retrospective study examined PTBS patients who underwent stenting and removal of a silicone stent.METHODS:Incomplete bronchial stenosis was defined as PTBS other than total bronchial obstruction, which had a luminal opening at the stenotic segment on bronchoscopic intervention. The duration of stenting was defined as the interval from stent insertion to removal. The study included 44 PTBS patients and the patients were grouped at intervals of 6 months according to the duration of stenting.RESULTS:Patients stented for more than 12 months had a significantly lower restenosis rate than those stented for less than 12 months (4% vs. 35%, P = 0.009). Multiple logistic regression revealed an association between stenting for more than 12 months and a low restenosis rate (odds ratio 12.095; 95% confidence interval 1.097-133.377). Moreover, no restenosis was observed in PTBS patients when the stent was placed more than 14 months previously.CONCLUSIONS:In patients with incomplete PTBS, stent placement for longer than 12 months reduced restenosis after stent removal.

Posttuberculosis Tracheobronchial Stenosis: Use of CT to Optimize the Time of Silicone Stent Removal

To evaluate whether air pockets (tracheobronchial air columns in the space between the outer surface of the stent and the adjacent airway wall) discernible at computed tomography (CT) can help optimize the time of stent removal in patients with posttuberculosis tracheobronchial stenosis (PTTS). The study was approved by the institutional review board, and informed consent was obtained from all patients. Data from 41 patients (five men, 36 women) with a median age of 39 years (range, 21-64 years) who underwent silicone stent placement owing to PTTS, followed by CT and stent removal 6-12 months after clinical stabilization, were investigated retrospectively. Two radiologists determined whether the extent of air pockets on CT scans was associated with clinical success, which was defined as maintenance of a prosthesis-free airway for more than 2 years after stent removal. Radiologic features were compared for outcome by using a Wilcoxon two-sample test or Fisher exact test. Stents were removed successfully in 31 patients (76%). Air pockets longer than 1 cm or longer than 2 cm were associated with successful stent removal (P = .04 and P = .006, respectively). The sensitivity and specificity of air pocket length in the prediction of successful stent removal were 84% and 50%, respectively, for air pockets longer than 1 cm and 68% and 70% for air pockets longer than 2 cm. The extent of air pockets at chest CT shows correlation with the success of stent removal, indicates regression of stenosis, and may help guide the optimal time for stent removal.

Pyelonephritis and Bacteremia From Lactobacillus acidophilus

Lactobacillus species have been uncommonly reported to cause clinically significant infections in both immunocompetent and immunocompromised hosts. Lactobacillus bacteremia of renal origin remains a rare clinical entity. We describe a case of pyelonephritis and bacteremia from Lactobacillus acidophilus . To our knowledge, this is only the fourth reported case of pyelonephritis caused by Lactobacillus . We report the case of a 63 year old African American female who had a history of right sided nephrolithiasis and hydronephrosis with recent right ureteral stent placement. She was admitted with pyelonephritis and the ureteral stent was subsequently removed. A new right ureteral mass was discovered at the time of stent removal and biopsy revealed high grade urothelial carcinoma. Blood and urine cultures grew Lactobacillus acidophilus . Antibiotic therapy was directed according to susceptibility pattern. Lactobacillus should be considered as a pathogen when it is isolated (in the appropriate clinical setting) from at least two blood cultures or in one blood culture along with another source especially when the host has one or more predisposing conditions. Lactobacillus species are associated with unusual antimicrobial susceptibility patterns. Lactobacillus should be a suspected pathogen in patients with bacteremia due to gram-positive rods whose condition does not improve with vancomycin therapy. doi:10.4021/jmc638e

Pyelonephritis and Bacteremia From Lactobacillus acidophilus

Lactobacillus species have been uncommonly reported to cause clinically significant infections in both immunocompetent and immunocompromised hosts. Lactobacillus bacteremia of renal origin remains a rare clinical entity. We describe a case of pyelonephritis and bacteremia from Lactobacillus acidophilus . To our knowledge, this is only the fourth reported case of pyelonephritis caused by Lactobacillus . We report the case of a 63 year old African American female who had a history of right sided nephrolithiasis and hydronephrosis with recent right ureteral stent placement. She was admitted with pyelonephritis and the ureteral stent was subsequently removed. A new right ureteral mass was discovered at the time of stent removal and biopsy revealed high grade urothelial carcinoma. Blood and urine cultures grew Lactobacillus acidophilus . Antibiotic therapy was directed according to susceptibility pattern. Lactobacillus should be considered as a pathogen when it is isolated (in the appropriate clinical setting) from at least two blood cultures or in one blood culture along with another source especially when the host has one or more predisposing conditions. Lactobacillus species are associated with unusual antimicrobial susceptibility patterns. Lactobacillus should be a suspected pathogen in patients with bacteremia due to gram-positive rods whose condition does not improve with vancomycin therapy. J Med Cases. 2012;3(4):223-225 doi: https://doi.org/10.4021/jmc638e

A solution for medical and legal problems arising from forgotten ureteral stents: initial results from a reminder short message service (SMS)

The objective of this study was to describe and present the initial results of a computer-based system that tracks ureteral stents and automatically sends a reminder through a short message service (SMS) to both the patient's and the urologist's mobile phones Using an integrated stent register program (SRP) and a stent extraction reminder program (SERP) with an electronic patient record program (EPRP) located within our hospital's computer network. In this system, the demographic data of all of the patients are recorded into the password-protected EPRP. After a stent is inserted, the surgeon enters the details of the operation into the EPRP. The SRP automatically asks the user to define the "optimal stent life (OSL)". The SERP checks the recorded patients daily and sends an SMS reminder to staff and patient when the OSL is reached. The SERP continues to send reminders via the SMS until stent is removed. We analyzed the success of the SMS recall system. A total of 186 patients received stents over an 11-month period. The patients in group-2 (n = 108) were recalled by the SERP, and the remainder of the patients (n = 78, group-1) were not included in the project. The mean delay from the designated OSL to the time of stent removal was 307 ± 118.6 (72-1,344) and 14.6 ± 2.06 (5-36) h in groups 1 and 2, respectively (p < 0.0001). Our initial results showed that the SRP and SERP prevent stent removal from being forgotten, thus preventing related medical and legal problems.

A multicenter analysis of safety and outcome of removal of a fully covered self-expandable metal stent during ERCP

Fully covered self-expandable metal stents (FCSEMSs) have been used for palliation of both malignant and benign biliary strictures. Limited data are available about safety and outcome of endoscopic removal of these stents. To evaluate safety and efficacy of endoscopic removal of FCSEMSs. Retrospective review of patients who underwent endoscopic removal of Viabil FCSEMSs. Four centers with experience in using FCSEMSs. Thirty-seven patients who had stents endoscopically removed. ERCP with endoscopic removal of FCSEMSs. Feasibility, safety, and complications associated with endoscopic removal of FCSEMS. All 37 stent removal attempts were successful and were achieved without difficulty. Indwelling stent-related complications occurred in 4 of 37 patients, including secondary strictures in 3 and minor bile leak in 1. Two of 3 secondary strictures occurred at the distal stent margin of oversized intraductal stents, and another stricture occurred at a proximal stent margin of an oversized transpapillary stent. One case of minor confined intratumoral bile leak also occurred in a patient with metastatic urothelial cancer of the bile duct. All of these cases were successfully treated with repeat stenting and resolved without sequelae. No free perforations or significant bleeding occurred. Retrospective study. Endoscopic removal of Viabil FCSEMSs placed for benign or malignant conditions is feasible and easily accomplished. Secondary strictures may be found at the time of stent removal or with a delayed presentation in patients with oversized stents who may require repeat stent placement.

171 The Incidence and Endoscopic Management of Recurrent Post-Orthotopic Liver Transplantation (OLT) Biliary Strictures After Initial Successful Endoscopic Management

The Incidence and Endoscopic Management of Recurrent PostOrthotopic Liver Transplantation (OLT) Biliary Strictures After Initial Successful Endoscopic Management Mehul M. Patel, Aaron B. Trimble, Isaac Galandauer, Jason Broker, Shireen A. Pais, Patricia Sheiner, Edward Lebovics Division of Gastroenterology and Hepatobiliary Diseases, Westchester Medical Center, Valhalla, NY; Division of Liver Transplant and Hepatobiliary Surgery, Westchester Medical Center, Valhalla, NY Background: Successful endoscopic management of post-OLT strictures with multiple parallel stents has been reported. Few data on the incidence and management of recurrent strictures. Methods: We conducted a retrospective study of post-OLT pts who had prior successful endoscopic therapy of a biliary stricture and developed recurrent stricture. Primary management of strictures was initially by single stent placement. If the stricture persisted at the time of stent removal, parallel stents were placed. The number of parallel stents was increased every 4-8 weeks until the maximum number felt to safely accommodate the duct was reached. Endoscopic success was defined by radiologic improvement, improved liver enzymes, and ability to pass a balloon 12mm across the stricture with minimal resistance. Biliary reconstruction was undertaken for endoscopic failures or progressive liver dysfunction. Pts in which recurrent strictures developed after initial successful endoscopic management were considered for retreatment. Pts currently undergoing primary endoscopic therapy who have not yet reached an endpoint were excluded. Outcomes of stent therapy were examined based on stricture location. Results: From 3/01 to 6/10, OLT was performed in 495 pts of whom 128 (26%) underwent 397 ERCPs (mean 3.1 ERCP per pt). Biliary strictures were seen in 86 (17.4%) pts of whom 69 (80%) had only anastomotic strictures (AS), 13 (15%) had both AS and non-anastomotic strictures (NAS) and 4 (5%) had only NAS. Of 62 pts with AS who reached an endpoint, 50 (80.6%) were treated successfully, 12 (19.3%) failed treatment and required surgical intervention. Of the 50 pts with successful AS treatment, 10 (20%) had recurrent strictures; 8 (80%) successfully retreated, 2 (20%) failed re-treatment. AS pts with or without recurrence did not significantly differ in the number of ERCPs until initial success, maximum number of parallel stents, or duration of initial stent therapy. Of 13 pts with both AS and NAS, 10 pts reached an end point; 6 (60%) were treated successfully, 4 (40%) failed treatment. 1 of 6 pts that were treated successfully developed a recurrent stricture, failed a second treatment, and ultimately required re-transplant. The 4 pts with NAS all failed endoscopic treatment and required surgical intervention. The mean time from primary stricture resolution to recurrence was 107 57 days. Overall 23 of 86 (26.7%) pts required biliary reconstruction. All 9 pts with intra-hepatic strictures required repeat OLT. Conclusions: 1. Successful endoscopic therapy of post-OLT AS carries a high recurrence rate of 20% requiring vigilant monitoring; 2. Repeat endoscopic therapy of recurrent AS has a similar success rate (80%) as primary therapy resulting in 20% of prior responders proceeding to surgical biliary reconstruction; 3. NAS do not respond well to endoscopic therapy.

Is Removal of the Stent at the End of 2 Weeks Helpful to Reduce Infectous or Urologic Complications After Renal Transplantation?

Objective Ureteral stents are used to reduce urologic complications after renal transplantation. However, they predispose to infection. The optimal time to keep them in the urinary tract has not yet been defined. The aim of this study was to evaluate the effect of early removal at the end of 2 weeks on urinary tract infections and early urologic complications (within 3 months), such as ureteroneocyctostomy leakage as well as ureteral anastomosis stricture or obstruction. Methods We retrospectively analyzed the medical records of 48 patients who underwent renal transplantation using a ureteral stent. The patients were divided into two groups according to the time of stent removal: at the end of 2 weeks (group A; n = 10) versus at a later time (group B; n = 38). Results The urologic complication rate was 0% in group A and the urinary tract infection rate, 2%. The urologic complication rate was 0% in group B and the urinary tract infection rate, 35%. Conclusion Early removal of the stent at the end of 2 weeks after renal transplantation is decreased the rate of urinary tract infections.

Long-term follow-up after biliary stent placement for postcholecystectomy bile duct strictures: a multicenter study

Endoscopic stenting is a recognized treatment of postcholecystectomy biliary strictures. Large multicenter reports of its long-term efficacy are lacking. Our aim was to analyze the long-term outcomes after stenting in this patient population, based on a large experience from several centers in France. Members of the French Society of Digestive Endoscopy were asked to identify patients treated for a common bile duct postcholecystectomy stricture. Patients with successful stenting and follow-up after removal of stent(s) were subsequently included and analyzed. Main outcome measures were long-term success of endoscopic stenting and related predictors for recurrence (after one stenting period) or failure (at the end of follow-up). A total of 96 patients were eligible for inclusion. The mean number of stents inserted at the same time was 1.9±0.89 (range 1-4). Stent-related morbidity was 22.9% (n=22). The median duration of stenting was 12 months (range 2-96 months). After a mean follow-up of 6.4±3.8 years (range 0-20.3 years) the overall success rate was 66.7% (n=64) after one period of stenting and 82.3% (n=79) after additional treatments. The mean time to recurrence was 19.7±36.6 months. The most significant independent predictor of both recurrence and failure was a pathological cholangiography at the time of stent removal. Endoscopic stenting helps to avoid surgery in more than 80% of patients bearing postcholecystectomy common bile duct strictures. However, a persistent anomaly on cholangiography at the time of stent removal is a strong predictor of recurrence and may lead to consideration of surgery.

Prophylactic urethral stenting with Memokath® 028SW in prostate cancer patients undergoing prostate 125I seed implants: phase I/II study.

PurposeTo study the feasibility/toxicity of urethral stenting with the Memokath® 028SW stent in patients undergoing prostate implant (PI) for prostate adenocarcinoma.Material and methodsAn Investigational Device Exemption from the Food and Drug Administration (FDA) and institutional review board (IRB) approval were obtained. Twenty patients enrolled. Baseline American Urological Association (AUA) score was obtained prior to PI. Follow-up information was obtained with weekly phone calls for the first 12 weeks and biweekly calls for the next 12 weeks to assess toxicity and AUA score. Removal of the stent was planned at six months after PI, or earlier due to excessive toxicity/patient request.ResultsMedian age was 66.5 years. The median prostate volume was 39 cc (range: 10-90). The median baseline AUA score was 7.5 (range: 1-21). Three patients required intermittent self-catheterization (ISC) within 3 days after PI. No patients required ISC beyond day 3 after PI. The median duration of ISC was 1 day (range: 1-2). AUA scores returned to baseline values 6 weeks after PI. The week 6 AUA score was 10 (range: 4-16). Seven patients (35%) underwent early removal because of patient preference. The reasons were: incontinence (n = 3), discomfort (n = 2), hematuria (n = 1), and obstructive symptoms (n = 1). The median time of stent removal in these patients was 13.9 weeks (range: 0.9-21.4). Thirteen patients (65%) had ISC and/or urinary catheterization post stent removal. Median time for ISC use was 10 days (range: 1-90).ConclusionsUrethral stenting with Memokath® in patients undergoing PI was feasible, but resulted in relatively high rate of urinary incontinence and discomfort. Given the adverse effects experienced by patients of this study, further studies should focus only on patients with highest risk of urinary obstruction from PI or those with obstruction needing ISC.

Is Repeat ERCP at Time of Stent Removal in Patients With Post-cholecystectomy Bile Leak a Necessity?

Is Repeat ERCP at Time of Stent Removal in Patients With Post-cholecystectomy Bile Leak a Necessity?

Temporary Use of a Fully Covered Self-Expandable Metal Stent for Treatment of Bariatric Surgery Complications

Purpose: Fully covered self expandable metal stents (FCSEMS) have been used in selected cases to manage post-bariatric surgical complications, though the data are limited. Such complications include gastric body strictures (sleeve gastrectomy), anastomotic strictures (Roux-en-Y gastric bypass), and fistulae. Aim: To report the outcome following FCSEMS placement for management of post-bariatric surgery complications using one type of FCSEMS. Methods: The medical records of all patients having undergone placement of one type of FCSEMS (Alimaxx-E, Merit Medical Systems, Inc.) from 1/1/2005 to 5/17/2010 were reviewed after IRB consent was obtained. 165 patients were initially identified and 15 of these had a FCSEMS placed exclusively to treat a complication resulting from bariatric surgery or surgical revision of a prior bariatric surgery. Data were abstracted for patient demographics, indications for stent placement, technical success, clinical outcomes, and stent related complications. Results: The 15 patients (mean age 48 years, 10 female) included 11 Rouxen-Y gastric bypass, 3 duodenal switch, and one sleeve gastrectomy patient. Indications for FCSEMS placement were stricture (9 patients), fistula (3 patients), and both stricture and fistula (3 patients). A total of 20 attempted FCSEMS placements occurred at a mean time of 514 days after surgery (range 14-1640 days). Technical success with placement was achieved in 19/20 attempts. Mean stent dwell time was 63 days. Endoscopic resolution of stricture was seen in 9/12 (75%) of stricture patients at time of stent removal, however, 7 of these patients developed recurrent strictures. Improvement in fistula was seen in 2/6 patients and did not required re-intervention up to 12 months after stent removal. Complications included 6 stent migrations, 2 of which lodged in the distal small bowel; one of these also caused a perforation and both required surgical removal/repair. A third stent migrated into the colon and was endoscopically removed. All other stents were completely removed by upper endoscopy; stent fragmentation during removal occurred in one case and was without sequela. Ultimately, 8/16 patients underwent surgery due to stricture recurrence or persistent fistulae despite FCSEMS placement. Conclusion: 1) Temporary placement of FCSEMS alone for management of post-bariatric surgery complications appears to have limited efficacy, with poor to moderate long term results. 2) Stent migration with subsequent small bowel obstruction or perforation was observed, and 50% of all patients required surgery for ultimate correction of their primary problem. 3) Adjuvant therapy such as fibrin glue could potentially improve outcome of fistula closure. Disclosure: Dr Johan C. Bakken: No financial disclosures Dr Wong Kee Song: No financial disclosures Dr Todd Baron - Paid Speaker: Alveolus, Inc.

Endoscopic Evaluation and Management of Autoimmune Pancreatitis Complicated with Pancreatic Ascites: A Case Report

Purpose: Autoimmune Pancreatitis (AIP) is a unique disease characterized by pancreatic inflammation and elevated serum IgG4 levels. Although the disease usually presents as a form of chronic pancreatitis, acute manifestations during a first episode or exacerbations are not uncommon. We describe the approach and management of a patient presenting with acute pancreatitis (AP) who developed multiple complications. Case report: An 18-year-old male with a 5-year history of recurrent pancreatitis and no other known diseases was hospitalized with severe abdominal pain, weight loss, ascites and left lower extremity deep vein thrombosis. Bloodwork upon admission included significant hipoalbuminemia (2.2 mg/dl) and a serum IgG4 markedly elevated at 533 mg/dL, with high total IgG levels at 2,012 mg/dL. Ascitic fluid analysis reported an amylase at 27,500 UI. Abdominal ultrasound showed evidence of portal vein thrombosis, ascities and acute pancreatitis. Computed tomography imaging demonstrated a dilated main pancreatic duct (PD) and a pancreatic head cystic lesion. Endoscopic ultrasound showed alterations compatible with severe acute pancreatitis complicated with fluid collections and ascites. An endoscopic retrograde cholangiopancreatography (ERCP) was performed, detecting rupture of the PD a pancreatic stent was placed. After marked improvement of ascites on the following 7 days, the patient was discharged and placed on oral anticoagulation. On outpatient follow-up, patient's ascites gradually resolved, his nutritional status improved and the pancreatic stent was removed after 8 weeks, documenting resolution of the PD rupture and a focal pancreatic duct stenosis at this level on ERCP, which was treated with balloon dilatation to 12 Fr. A prednisone regimen tapered to a maintenance dose of 5 to 10 mg/day was continued until clinical and laboratory evaluation fully resolved (length of follow-up). Discussion: Severe acute AIP with pancreatic duct disruption is uncommon and, as occurs with most pancreatitis, the approach for this complication is usually challenging. As reported in this case, conventional management with pancreatic stent placement and treatment of the primary etiology with close patient follow-up to determine the time of stent removal and further endoscopic treatment during ERCP as needed is recommended. Conclusion: Transpapillary pancreatic stent placement can be useful in the management of pancreatic ascites due to AIP and reduce the length of hospitalization and the need for more aggressive interventions in these patients.

Free Gingival Graft Immobilization: A Pilot Study on a Newly Designed Stent

The presence of adequate gingiva with firm attachment to the underlying periosteum and bone is important for the overall long-term success of implant-supported oral rehabilitation. In the presence of an atrophic edentulous mandible, peri-implant soft tissue management is a challenging task. Therefore, mucosal grafts are sometimes necessary in patients with insufficient attached gingiva around abutments. Immobilization of this graft is mandatory for its survival. The study design included 5 edentulous patients with inadequate attached gingival zone, all candidates for implant surgery and free gingival graft. In the first surgery the implants were inserted, and in the second operation a free gingival graft was obtained from the palate and sutured to the mandibular site. A newly designed stent was applied for the stabilization of the graft. Two to 3 weeks after the second surgery, the stents were removed and the attached gingival width was measured. Long-term evaluations were performed to follow the survival of the graft. All grafts were intact at the time of stent removal. In all cases, the long-term evaluations revealed adequate attached gingiva around the implant. It may be concluded that immobilization of free gingival graft in the recipient site increases its success rate and its survival rate. The application of the newly designed stent can serve as a proper and easy immobilizer for peri-implant soft tissue management.

Findings at endoscopic retrograde cholangiopancreatography after endoscopic treatment of postcholecystectomy bile leaks

Although the endoscopic management of bile leaks after cholecystectomy (CCY) is well established, the yield of a routine endoscopic retrograde cholangiogram (ERC) with a bile duct sweep at the time of stent removal is unclear. This study aimed to describe the prevalence of abnormal findings at follow-up ERC to determine whether upper endoscopy with stent removal and without cholangiography would suffice. A retrospective cohort analysis of all patients referred for initial and follow-up ERC with post-CCY bile leak was performed. The rate of abnormal findings was measured including choledocholithiasis, biliary strictures, and persistent bile leaks at follow-up ERC. Secondarily, the study sought to define the clinical characteristics of patients who demonstrated stones or sludge at follow-up assessment. Between January, 2003 and April, 2008, 105 patients underwent initial and follow-up ERC. After a mean interval of 6.9 +/- 2.7 weeks between endoscopies, 29 (27.6%) of the 105 patients demonstrated one or more abnormalities including persistent bile leak (n = 8), common bile duct (CBD) stones (n = 12), and CBD sludge alone (n = 9). In the subgroup analysis of the patients who underwent a balloon sweep at initial and follow-up ERC, the prevalence of CBD stones or sludge at the follow-up ERC was 17.6%. Besides stones during the initial ERC, no significant clinical predictors of CBD stones were found at follow-up ERC including surgical approach, interval between endoscopies, and location of bile leak. After endoscopic treatment of a bile leak, the prevalence of abnormalities at follow-up ERC is significant. A repeat cholangiogram with a balloon sweep is preferred at the time of stent removal.

Effectiveness of canalicular laceration repair using monocanalicular intubation with Monoka tubes

This study aimed to evaluate the clinical efficacy of canalicular laceration repair using monocanalicular intubation with Monoka tubes. A total of 36 single lacerated canaliculi were repaired using monocanalicular intubation with Monoka tubes, without mucosal anastomosis of the canaliculi, and were retrospectively reviewed. Demographic information, injury locations, associated ocular injuries, complications and outcomes were analysed. Mean patient age was 34 years (range 1-64 years). Tubes were removed at a mean of 4.2 months (range 3-6 months). There were 26 lower canalicular lacerations (72%) and 10 upper canalicular lacerations (28%). Overall, 34 of 36 cases (92%) showed improvement in symptoms and exhibited positivity on the dye disappearance test at 4-12 months after the procedure (mean 7.8 months). In total, 21 patients (58%) achieved complete success, 13 patients (36%) achieved partial success and two patients (6%) suffered surgical failure. Complications were seen in five cases and included two early tube protrusions, two punctal slits and one punctal granuloma. Monocanalicular intubation with Monoka tubes leads to successful outcomes without significant complications and offers an alternative to bicanalicular intubation in the treatment of monocanalicular lacerations.

Assessment of Need for Repeat ERCP During Biliary Stent Removal After Clinical Resolution of Postcholecystectomy Bile Leak

In patients who have undergone endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement for postcholecystectomy bile leak there is limited evidence to support the repeat ERCP at the time of stent removal. Esophagogastroduodenoscopy (EGD) with biliary stent removal may suffice. The aim of this study was to describe the clinical course of patients who underwent biliary stent placement for a postcholecystectomy bile leak and determine whether repeat ERCP is necessary. We identified all adult patients who underwent biliary stent placement for postcholecystectomy bile leak from 1 January 1996 to 31 October 2008. Demographic data, cholecystectomy details, and procedural data were collected, specifically focusing on closure of the bile leak. Time to resolution of leak was calculated, up to either the date of the first repeat ERCP that demonstrated no persistent leak or the date of removal of any radiologically placed percutaneous drain, whichever came first. Sixty-four patients underwent repeat ERCP with biliary stent removal. The median time to repeat ERCP was 36 days (interquartile range (IQR) 26-48). Fifty-seven (89%) patients had resolved the leak by time of repeat ERCP. Of those in whom the leak had not resolved, 6 had a repeat exam within 14 days of stent placement; 4 of these resolved the leak by day 39. There were no procedure-related complications in the ERCP group. Thirteen patients underwent EGD with stent removal after a median of 29 days (IQR 23-38). None had adverse events, with a median follow-up of 38 months. Overall, the median time to resolution of biliary leak was 33 days (IQR 22-44). Importantly, repeat ERCP altered the management in only one patient in whom bile duct stones were found. Patients with uncomplicated postcholecystectomy bile leak who have clinically resolved their leak do not require cholangiography at the time of stent removal. In these patients, EGD with stent removal at 4-6 weeks seems to be sufficient and significantly less expensive.

Alfuzosin to Relieve Ureteral Stent Discomfort: A Prospective, Randomized, Placebo Controlled Study

We assessed the impact of alfuzosin on ureteral stent discomfort. A total of 66 patients scheduled for unilateral retrograde ureteroscopy with stent placement provided consent for the study. Patients were randomized between placebo and the study medication, and investigators and patients were blinded to the randomization scheme. To evaluate pain and urinary symptoms patients were asked to complete the Ureteral Stent Symptom Questionnaire (Stone Management Unit, Southmead Hospital, Westbury-on-Trym, United Kingdom) before ureteroscopy and 3 days after the procedure to minimize the confounding impact of procedural discomfort due to surgery. Patients were also asked to maintain a use log of pain medication each day that the ureteral stent was in place. Procedure outcome and complications were recorded, as were patient study medication use and vital health information before the procedure and at the time of stent removal. Statistical analysis was performed using the Student t, chi-square and Wilcoxon rank sum tests, as appropriate, with p <0.05 considered significant. Of 66 patients who provided consent 55 successfully completed the study. In 3 of the 11 failed cases surgery was not done due to spontaneous stone passage, surgery was performed in 3 but no ureteral stent was placed, 4 were excluded from study after obtaining consent due to exclusion criteria and 1 was voluntarily removed from study after obtaining consent but before surgery. Regarding stent type, procedure complications and baseline questionnaire results there were no significant differences between the placebo and alfuzosin arms. When comparing post-procedure questionnaire results, patients in the alfuzosin arm reported less overall pain in the kidney/back/loin area and less pain in the kidney area while passing urine (p = 0.017 and 0.007, respectively). Men in the alfuzosin arm also reported a lesser incidence of excessive urination (p = 0.040). When comparing changes from baseline questionnaire results, the alfuzosin arm experienced a decrease in kidney pain during sleep (p = 0.017), less frequent use of painkillers to control kidney pain (p = 0.020) and a decrease in how much kidney associated pain interfered with life (p = 0.045). There was no significant difference in the amount of narcotics used per day, as reported in patient medication logs. Alfuzosin improves the patient discomfort associated with ureteral stents by decreasing urinary symptoms and kidney pain but it does not affect the amount of narcotics that patients use while the stent is in place.