Use Of Self-expanding Metal Stents Research Articles

Shorter interval to surgery after self-expanding metallic stent may result in better oncologic outcomes in colon cancer obstruction

IntroductionColon cancer obstruction is one of the most serious conditions in colorectal surgery. However, the use of self-expanding metallic stent (SEMS) has made it possible to avoid emergency surgery and stoma creation, therefore enabling minimally invasive surgery and one-stage operation. In this study, we aimed to investigate whether there is an optimal interval from SEMS to surgery for the best long-term oncologic outcomes. MethodsObstructive colon cancer patients treated with SEMS insertion and received surgery were included in the study. Patient data were retrospectively reviewed in prospectively collected data. Using the ROC curve, the optimal interval to surgery after SEMS insertion was 10 days; the patients were divided into the early surgery group (≤ 10 days, ES) and the late surgery group (>10 days, LS). Factors contributing to the 5-year disease-free survival (DFS) and overall survival (OS) were analyzed. Results83 patients were included in this study. Eight patients (9.6%) had SEMS insertion failure, with 3 perforations and 5 failed expansions. There were no differences between the ES group and the LS group in terms of pathologic characteristics, incidence of stoma creation, and adjuvant chemotherapy. Twenty-six patients (31.3%) had recurrences; local (6), peritoneal seeding (8), liver (11), lung (7), bone (2), and abdominal wall metastasis (1). The 5-year DFS rate was significantly better in the ES group than the LS group (74.3% vs. 55.01%; p=0.0394). The 5-year OS was slightly better in the ES group than the LS group (76.11% vs. 58.75%; p=0.0901). In univariable analysis, the ES group showed a lower risk of recurrence than the LS group (OR: 0.447 [0.204-0.984], p=0.0455), but this was not reproduced in the multivariable analysis. ConclusionThis study has shown that the long-term oncologic outcomes were better in patients who received surgery after SEMS within 10 days. Hence, we propose with caution that elective surgery might be suggested to take place within 10 days from SEMS insertion for better oncologic outcomes.

Role of advanced endoscopy in the management of inflammatory digestive diseases (pancreas and biliary tract).

The progress of endoscopic diagnosis and treatment for inflammatory diseases of the biliary tract and pancreas have been remarkable. Endoscopic ultrasonography (EUS) and EUS-elastography are used for the diagnosis of early chronic pancreatitis and evaluation of endocrine and exocrine function in chronic pancreatitis. Notably, extracorporeal shock wave lithotripsy and electrohydraulic shock wave lithotripsy have improved the endoscopic stone removal rate in patients for whom pancreatic stone removal is difficult. Studies have reported the use of self-expanding metal stents for stent placement for pancreatic duct stenosis and EUS-guided pancreatic drainage for refractory pancreatic duct strictures. Furthermore, EUS-guided drainage using a double-pigtailed plastic stent has been performed for the management of symptomatic pancreatic fluid collection after acute pancreatitis. Recently, lumen-apposing metal stents have led to advances in the treatment of walled-off necrosis after acute pancreatitis. EUS-guided biliary drainage is an alternative to refractory endoscopic biliary drainage and percutaneous transhepatic biliary drainage for the treatment of acute cholangitis. The placement of an inside stent followed by switching to uncovered self-expanding metal stents in difficult-to-treat cases has been proposed for acute cholangitis by malignant biliary obstruction. Endoscopic transpapillary gallbladder drainage is an alternative to percutaneous transhepatic gallbladder drainage for severe and some cases of moderate acute cholecystitis. EUS-guided gallbladder drainage has been reported as an alternative to percutaneous transhepatic gallbladder drainage and endoscopic transpapillary gallbladder drainage. However, it is important to understand the advantages and disadvantages of each drainage method and select the optimal drainage method for each case.

Characteristics of four commonly used self-expanding biliary stents: an in vitro study

BackgroundKnowledge of the characteristics of self-expanding metal stents (SEMSs) is essential during selection process to ensure the best therapeutic outcomes for patients with malignant biliary obstruction. The aim of this study was to evaluate the characteristics of four commonly used SEMSs.MethodsThis in vitro study analyzed the radial force (RF), crush resistance (CR), axial force (AF), conformability, surface quality, foreshortening, and radiopacity of the following SEMSs: uncovered Wallflex™, EGIS single bare, Zilver 635®, and E-Luminexx™. Two samples of each SEMS type were included in this study, all having identical specifications with a diameter of 10 mm and a length of 6 cm. One sample from each type was analyzed for surface quality, followed by CR, conformability, and foreshortening. The other sample was analyzed for radiopacity, followed by RF and AF.ResultsThe uncovered Wallflex™ exhibited low RF, high CR, high AF, good conformability, poor surface quality, high foreshortening, and good radiopacity. The EGIS single bare demonstrated high RF, high CR, low AF, moderate conformability, good surface quality, high foreshortening, and poor radiopacity. The Zilver 635® displayed moderate RF, low CR, low AF, moderate conformability, moderate surface quality, no foreshortening, and good radiopacity. The E-Luminexx™ showed high RF, moderate CR, high AF, poor conformability, poor surface quality, no foreshortening, and good radiopacity.ConclusionsThere was considerable variation in the characteristics among the four evaluated SEMSs. These characteristics should be carefully considered during selection to ensure optimal therapeutic outcomes for patients.Relevance statementThe selection of self-expanding metal stents for treating malignant biliary obstruction requires careful consideration of various characteristics, including their radial force, crush resistance, axial force, conformability, surface quality, foreshortening, and radiopacity.Key points• The characteristics of self-expanding metal stents (SEMSs) can vary considerably.• Specific situations may warrant the use of SEMSs with particular characteristics over others.• Characteristics of SEMSs must be considered during selection for optimal outcomes.Graphical

Esophageal Stent in Acute Refractory Variceal Bleeding: A Systematic Review and a Meta-Analysis.

Background: Acute esophageal variceal bleeding accounts for up to 70% of upper-gastrointestinal bleeding in cirrhotic patients. About 10-20% of patients with acute variceal bleeding have refractory bleeding that is not controlled by medical or endoscopic therapy, and this condition can be life-threatening. Balloon tamponade is a long-standing therapy which is only effective temporarily and has several complications, while transjugular intrahepatic portosystemic shunt (TIPS) and liver transplantation may not be readily available at some centers. The use of self-expandable metal stents (SEMSs) in refractory esophageal variceal bleeding has been studied for effectiveness and adverse events and has been recommended for use as a bridge to a more definitive treatment. Aim: To investigate the effectiveness and safety of SEMSs in managing refractory variceal bleeding. Methods: A systematic search of the MEDLINE, EMBASE, and Cochrane library databases was performed from inception to October 2022 using the following terms: "esophageal stent", "self-expandable metal stents", "endoscopic hemostasis", "refractory esophageal varices", and "esophageal variceal bleeding". Studies were included in the meta-analysis if they met the following criteria: (1) patients' age older than 18 and (2) a study (or case series) that has at least 10 patients in the study. Exclusion criteria included (1) non-English publications, (2) in case of overlapping cohorts, data from the most recent and/or most appropriate comprehensive report were collected. DerSimonian-Laird random-effects meta-analysis was performed using the meta package in R statistical software(version 4.2.2). Results: Twelve studies involving 225 patients with 228 stents were included in the analyses. The mean age and/or median age ranged from 49.4 to 69 years, with a male-to-female ratio of 4.4 to 1. The median follow-up period was 42 days. The mean SEMS dwell time was 9.4 days. The most common cause of acute refractory variceal bleeding in chronic liver disease patients included alcohol use followed by viral hepatitis. The pooled rate of immediate bleeding control was 91% (95% CI 82-95%, I2 = 0). The pooled rate of rebleeding was 17% (95% CI 8-32%, I2 = 69). The pooled rate of stent ulceration was 7% (95% CI 3-13%, I2 = 0), and the pooled rate of stent migration was 18% (95% CI 9-32%, I2 = 38). The pooled rate of all-cause mortality was 38% (95% CI 30-47%, I2 = 34). Conclusions: SEMSs should be primarily considered as salvage therapy when endoscopic band ligation and sclerotherapy fail and can be used as a bridge to emergent TIPS or definitive therapy, such as liver transplantation.

Performance of biliary stents in malignant biliary strictures.

Endoscopic stenting is a commonly applied method of treatment in patients with malignant biliary strictures. It involves the use of self‑expandable metal stents (SEMSs) or plastic stents (PSs). The aim of the study was to compare the effectiveness of SEMSs and PSs in the endoscopic drainage of malignant strictures of the biliary tree and its sequels for future optimalization of this treatment method. Data on 618 consecutive patients with malignant biliary stricture, in whom 1271endoscopic retrograde cholangiopancreatography procedures with biliary stenting have been performed in the years 2012-2017 with at least 3‑year follow‑up, were retrospectively derived from a hospital database. The main indications for stenting were pancreatic cancer (37%) and cholangiocarcinoma (34%). The use of SEMSs resulted in a greater decline of serum bilirubin as compared with PSs (37% vs 32% of baseline concentration; P = 0.01). Consequently, hospital stay was shorter by more than 2 days (mean [SD], 9.5 [5.6] vs 11.8 [7.9] days; P <0.001). The median (interquartile range) patency time of SEMSs was more than 2 times longer than for PSs (118 [56-232] days vs 46 [18-97] days; P <0.001), and procedure‑related complications were less frequent (19.3% vs 12.9%, respectively in the SEMS and PS group; P = 0.001). SEMSs proved also to be more cost‑effective; the hospital profit was 1375 USD for a single hospitalization with SEMS insertion. In patients with malignant strictures of the biliary tree SEMSs outperform PSs. SEMSs should be used as a treatment of choice for biliary drainage in that group of patients.

Biliary drainage in hilar and perihilar cholangiocarcinoma: 25-year experience at a tertiary cancer center

This study analyzed the optimal biliary stenting strategy for palliation in cholangiocarcinoma (CCA). This was a retrospective study of patients with CCA who underwent biliary drainage from 1997 to 2023. A per-patient analysis of percutaneous transhepatic biliary drainage (PTBD) rates, the median number of ERCPs, and overall survival (OS) and a per-procedure analysis of clinical success (CS), stent-specific adverse events (AEs), and mean time to repeat ERCP by stent type and laterality (unilateral and bilateral) are presented. A total of 333 patients underwent 1050 ERCPs, 85% with plastic stents (PSs). PTBD was eventually done in 23% of PS patients, 35% of whom had their PS removed before PTBD. ERCPs with the use of self-expandable metal stents (SEMSs)/unilateral SEMSs had higher CS (89%/91%) versus PSs/unilateral plastic stents (uPSs) (85% both) and PSs within SEMSs (PS-SEMSs)/uPS-SEMSs (71%/74%; P= .013/P= .054). Compared with PSs, SEMSs and PS-SEMSs were associated with higher stent-specific AEs (odds ratios [ORs]: SEMSs 4.85 [95% confidence interval (CI), 3.23-7.27], PS-SEMSs 9.99 [95% CI, 5.33-18.71]; P< .001). Straight PSs were associated with more stent-specific AEs compared with double-pigtail stents (OR 6.74 [95% CI, 3.95-11.45]; P< .001). More 7F stents were used in cases with balloon dilation (BD) (109 with BD vs 88 without BD; P< .001). BD had a 79% CS rate versus 87% without BD (P< .001). Cases with pus on ERCP and those with BD had a shorter mean time to repeat ERCP. On regression analyses, higher Bismuth class, PS use, and PS-SEMS use were associated with a shorter mean time to repeat ERCP. Fifty-two percent of patients in the bilateral SEMS arm died from cholangitis (P= .005). The relatively higher CS rate of SEMSs is countered by the higher stent-specific AE rate. PSs can be removed and may better facilitate PTBD. Within PS types, double-pigtail stents may have fewer stent-specific AEs. Cases requiring BD and with endoscopic evidence of pus may benefit from earlier reintervention.

251 Use of Self-expanding Metal Stents (SEMS) in Emergency Colonic Obstruction (a retrospective study)

Abstract Aim Colorectal cancer is becoming increasingly common in UK, presenting as an emergency in 20% of cases. This carries significantly higher (six-fold) mortality compared with an elective presentation. There is high level evidence that self-expanding metal stents (SEMS) can be successfully used both for palliation (as a definitive procedure) and as a bridge to surgery (BTS) in patients with colorectal cancer. ACPGBI consensus guidelines in emergency general surgery suggest expected success rate of 90% whilst requesting units to audit their figures to evaluate success rates and complications. Method We performed a retrospective audit of SEMS placement over nearly 5-year period in our colorectal unit (spanning from July 2016 to May 2021). We accessed local reporting systems and electronic patient notes for pathology, site, results and outcome post attempted stenting. Results Total number of SEMS inserted = 30. One patient was excluded due to incomplete data present. Male:female ratio = 1.5:1. Mean age at application = 71.5 (range 37-96). Most common site was sigmoid (48%), followed by descending colon (28%). Success rate was 86%. Majority of SEMS were used as a palliative procedure - 86% vs 10% as BTS. 10% of patients had complications following stent insertion, including blockage and leak, in all cases leading to emergency Hartmann’s procedure. Conclusions Data shows significant SEMS use locally particularly for palliation. Success rates are comparable with national and show stenting can be performed by an experienced radiologist. However, complication risks are not insignificant, and patients should be counselled accordingly prior to procedure.

5-year oncological outcomes in left-sided malignant colonic obstruction: stent as bridge to surgery

BackgroundA considerable number of patients with colon cancer present with a colonic obstruction. The use of self-expanding metallic stents (SEMS) as a bridge to surgery (BTS) in potential curative patients with left-sided colonic cancer obstruction remains debatable. Therefore, this study aimed to investigate the 5-year oncological outcomes of using a SEMS as a BTS.MethodsAll patients with left-sided malignant colon obstruction who underwent curative surgery with no metastasis upon presentation between March 2009 and May 2013 were retrospectively reviewed and analyzed.ResultsA total of 45 patients were included, 28 patients underwent upfront surgery, and 17 patients had a stent as a bridge to surgery. T4 stage was statistically significantly higher in patients who had a SEMS as a BTS (35.3% vs. 10.7%) (p-value 0.043). The mean duration in days of the SEMS to surgery was 13.76 (SD 10.08). TNM stage 3 was a prognostic factor toward distant metastasis (HR 5.05). When comparing patients who had upfront surgery to those who had a SEMS as a BTS, higher 5-year disease-free survival (75% vs. 72%) and 5-year overall survival (89% vs. 82%) were seen in patients who had upfront surgery. However, both were statistically insignificant.ConclusionUsing self-expanding metallic stents as a bridge to surgery yields comparable 5-year survival and disease-free survival rates to upfront emergency surgery. The decision to use SEMS versus opting for emergency surgery should be made after careful patient selection and with the assistance of experienced endoscopists.Trial registrationN/A.

Optimizing biliary stenting in patients with distal malignant biliary obstruction.

Endoscopic biliary stenting plays a crucial part in the management of patients with malignant biliary strictures (MBSs), not only in a palliative setting where there is metastatic disease, but also in allowing neoadjuvant chemotherapy to be given before surgery [1]. The use of self-expandable metal stents (SEMSs) is preferred to plastic stents, as SEMSs are associated with a longer patient survival, a lower risk of stent dysfunction/cholangitis, and fewer reinterventions [1]. Fully covered SEMSs (FCSEMSs) have the advantage of being less prone to obstruction owing to tissue ingrowth, which allows easier stent removal; on the other hand, migration, into the duodenal lumen or even in an intrabiliary direction, can be of a major concern [2]. Neoadjuvant chemotherapy seems to be an additional risk factor that favors migration, which relates to the reduction in tumoral tissue [3]. Another debatable concern with the use of FCSEMSs is the incidence of cholecystitis, especially in patients presenting with tumor involvement of the cystic duct [3].

Colonic stent for bridge to surgery for acute left-sided malignant colonic obstruction: A review of the literature after 2020

It has been found that 8%-29% of colorectal cancers are obstructive. The use of "stent as bridge to surgery" is one of the most debated topics in obstructive left-sided colorectal cancer management. The endoscopic placement of a self-expanding metallic stent as bridge to surgery (BTS) could turn an emergency surgery to an elective one, increasing the number of primary anastomoses instead of stoma and facilitating the laparoscopic approach instead of an open one. However, in recent years the possible risk of perforations and microperforations facilitating cancer spread related to the use of self-expanding metallic stent for BTS has been highlighted. Therefore, despite the useful short-term outcomes related to BTS, the recent literature has focused on long-term outcomes investigating the disease-free survival, the recurrence rate and the overall survival. Due to discordant data, international guidelines are still conflicting, and the debate is still open. There is not agreement about using self-expanding metallic stent for BTS as the gold standard.

Outcome of metal vs plastic stents for biliary obstruction in patients with pancreatic carcinoma undergoing neoadjuvant chemoradiotherapy: A systematic review and meta-analysis.

Preoperative biliary drainage (PBT) may be warranted in patients with borderline resectable or locally advanced pancreatic carcinoma before neoadjuvant therapy (NAT) to relieve obstructive jaundice. However, it is unclear if the use of self-expanding metal stents (SEMS) has any benefit over plastic stents in this setting. We searched electronic databases from inception to February 11, 2022 to identify studies comparing SEMS and plastic stents for PBT in patients with pancreatic carcinoma undergoing NAT. Random effect models were used to determine pooled rates of recurrent biliary obstruction (RBO) and/or need for reintervention, stent-related complications and surgical outcome. A total of 10 studies (474 patients; metal group-37.1%) were included. Pooled risk ratio of RBO and/or need for reintervention was lower in the metal group (RR, 0.23 [95% CI: 0.11-0.45, I2 = 60%]). Pooled risks of stent occlusion (RR, 0.43 [95% CI: 0.24-0.80, I2 = 45%]) and stent-related cholangitis (RR, 0.37 [95% CI: 0.17-0.78, I2 = 1%]) were lower in the metal group. However, risks of stent-related cholecystitis (RR, 1.51 [95% CI: 0.36-6.41, I2 = 0%]) and pancreatitis (RR, 1.52 [95% CI: 0.07-31.84, I2 = 66%]) were higher in the metal group. The metal group was also associated with a reduced risk of delay in NAT (RR, 0.38 [95% CI: 0.18-0.80, I2 = 14%]). Pooled risk ratio of R0 resection and postoperative complications was equal amongst both groups. Metal stents are associated with reduced risk of RBO and/or need for reintervention, reduced risk of stent occlusion and cholangitis as compared to plastic stents in patients with pancreatic carcinoma undergoing NAT.

Multilevel stenting of malignant colonic obstructions from multilevel breast cancer colonic metastasis.

Video 1A video depicting the enclosed case, procedure, and discussion.

Predictors of clinical outcomes of self-expandable metal stent treatment for malignant colorectal obstruction: A Honam Association for the Study of Intestinal Disease (HASID) multicenter study.

There has been increased use of self-expandable metal stents (SEMS) in treating malignant colorectal obstruction (MCO). The aim of this study was to investigate factors that are associated with the outcomes of SEMS placement for MCO.Clinical data from patients who underwent SEMS placement for MCO at 6 hospitals in Honam province of South Korea between 2009 and 2018 were reviewed retrospectively. Eight hundred two patients were identified and their data were analyzed. Technical success, clinical success, complications, and predictors of outcome were included as main outcome measures.Technical and clinical success rates were 98.8% (792/802) and 90.1% (723/802), respectively. Complications including stent migration, stent occlusion due to tumor ingrowth and outgrowth, perforation, bacteremia/fever, and bleeding occurred in 123 (15.3%) patients. In multivariate regression analyses, procedure time was significantly associated with the technical success of SEMS placement (P = .001). Longer length of obstruction, the use of covered stent, and longer procedure time were significant independent predictive factors for the clinical success of SEMS placement (odds ratio [OR] 0.974 (95% confidence interval [CI] 0.950–0.990); P = .043, OR 0.255 (95% CI 0.138–0.471); P < .001, and OR 0.957 (95% CI 0.931–0.984); P = .002, respectively). Stage IV colorectal cancer and the use of covered stent were significant independent predictive factors for the development of complications after SEMS placement (OR 2.428 (95% CI 1.407–4.188); P = .001 and OR 3.329 (95% CI 2.060–5.378); P < .001, respectively).Longer length of obstruction, the use of covered stent, and longer procedure time were associated with lower clinical success rates. Having stage IV colorectal cancer and the use of covered stents were associated with an increased risk of complications.

Tracheobronchial stents in patients with malignant airway disease: Finnish tertiary care experience.

Tracheobronchial stenting has an established role in the palliation of malignant central airway obstruction (CAO). The purpose of this study is to describe the experience with self-expanding metal airway stents in 2 tertiary referral centres, covering a third of the population of Finland. Patients referred to and treated with airway stenting for malignant CAO using self-expanding metal-stents were identified from electronic patient records, and data were collected using a structured Endoscopic Lower Airway Management instrument. Statistical analysis to reveal factors affecting patient benefit and survival was carried out. A total of 101 patients (mean age 65.8) and 116 procedures were identified. Procedure-related mortality was rare (3/101 patients) and complications infrequent. The median survival was 2.3 months [95% confidence interval (CI): 1.4-3.1). Stent benefit was not significantly affected by clinical characteristics. Survival was impacted by the use of adjunct procedures [hazard ratio (HR) 0.36, 95% CI: 0.23-0.58, P < 0.001), procedural urgency (HR 0.40; 95% CI: 0.23-0.71, P = 0.002) and post-treatment chemoradiotherapy (HR 0.29, 95% CI: 0.15-0.56, P < 0.001). The beneficial impact observed supports the further use of tracheobronchial stenting in malignant CAO. The use of self-expanding metal stents is encouraged.

Esophageal stenting for benign and malignant disease: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2021

1: ESGE recommends placement of partially or fully covered self-expandable metal stents (SEMSs) for palliation of malignant dysphagia over laser therapy, photodynamic therapy, and esophageal bypass.Strong recommendation, high quality evidence. 2 : ESGE recommends brachytherapy as a valid alternative, alone or in addition to stenting, in esophageal cancer patients with malignant dysphagia and expected longer life expectancy.Strong recommendation, high quality evidence. 3: ESGE recommends esophageal SEMS placement for sealing malignant tracheoesophageal or bronchoesophageal fistulas. Strong recommendation, low quality evidence. 4 : ESGE does not recommend SEMS placement as a bridge to surgery or before preoperative chemoradiotherapy because it is associated with a high incidence of adverse events. Other options such as feeding tube placement are preferable. Strong recommendation, low quality evidence. 5: ESGE recommends against the use of SEMSs as first-line therapy for the management of benign esophageal strictures because of the potential for adverse events, the availability of alternative therapies, and their cost. Strong recommendation, low quality evidence. 6: ESGE suggests consideration of temporary placement of self-expandable stents for refractory benign esophageal strictures. Weak recommendation, moderate quality evidence. 7: ESGE suggests that fully covered SEMSs be preferred over partially covered SEMSs for the treatment of refractory benign esophageal strictures because of their very low risk of embedment and ease of removability. Weak recommendation, low quality evidence. 8: ESGE recommends the stent-in-stent technique to remove partially covered SEMSs that are embedded in the esophageal wall. Strong recommendation, low quality evidence. 9: ESGE recommends that temporary stent placement can be considered for the treatment of leaks, fistulas, and perforations. No specific type of stent can be recommended, and the duration of stenting should be individualized. Strong recommendation, low quality of evidence. 10 : ESGE recommends considering placement of a fully covered large-diameter SEMS for the treatment of esophageal variceal bleeding refractory to medical, endoscopic, and/or radiological therapy, or as initial therapy for patients with massive bleeding. Strong recommendation, moderate quality evidence.

Use of self-expandable metallic stents for endoscopic biliary decompression decreases stent complications in pancreatic cancer patients receiving chemotherapy

BackgroundBoth plastic stents and self-expandable metallic stents (SEMSes) are used for endoscopic biliary decompression (BD) among patients with pancreatic cancer (PAC). Cholangitis or stent occlusion often interrupts or ends chemotherapy. We investigated cholangitis, stent occlusion, and chemotherapy interruption rates for SEMSes and plastic stents among patients receiving chemotherapy for PAC.Materials and methodsWe retrospectively analyzed data for 293 PAC patients who received a biliary stent at Helsinki University Hospital during 2000–2017. Patients received chemotherapy as palliative treatment (PT: n = 187) or neoadjuvant treatment (NAT: n = 106). Among participants, 229 had a plastic stent (PT: n = 138, NAT: n = 91) and 64 had a SEMS (PT: n = 49, NAT: n = 15).ResultsOverall, 15.6% (n = 10) of patients with SEMSes (PT: 20.4%, n = 10, NAT: 0%) and 53.0% (n = 121) of patients with plastic stents (PT: 69.3%, n = 95, NAT: 28.5%, n = 26) experienced one or more stent complications (p < 0.001). Cholangitis developed in 6.3% (n = 8) of PT patients with SEMSes. No patients with SEMSes receiving NAT (n = 15) experienced cholangitis. However, 31.9% (PT: 42.8%, n = 59, p = 0.001; NAT: 15.4%, n = 14, p = 0.211) of patients with plastic stents developed cholangitis. Among all patients receiving NAT or PT, cholangitis interrupted chemotherapy 6 times (9.4%) in SEMS patients and 61 times (26.6%) in plastic stent patients (p = 0.004). Stent occlusion without cholangitis interrupted NAT or PT 2 times (2.1%) in SEMS patients and 31 times (13.5%) in plastic stent patients (p = 0.023).ConclusionsSEMS is recommended for BD among patients with PAC receiving chemotherapy. Among both PT and NAT patients, patients with SEMS experience a lower stent failure rate, lower rate of cholangitis, and fewer chemotherapy interruptions than patients with plastic stents.

Self-Expanding Metal Stent (SEMS) Placement to Treat Bleeding from Late Radiation Esophagitis

Radiation esophagitis is a serious complication occurring in patients receiving radiotherapy for head and neck cancers. Current treatment with proton pump inhibitors and mucosal protectants provides symptomatic relief with few studies showing improvement in erosive esophagitis or ulceration. Use of self-expandable metal stents (SEMS) in cases of erosive radiation esophagitis refractory to medical therapy has not been studied. We report a case of a patient presenting with recurrent hematemesis from late (chronic) radiation esophagitis with bleeding esophageal ulceration successfully treated with SEMS placement after failure of conservative medical management, proposing a possible utility for SEMS in this setting.

Long-Term Success of Metal Endobronchial Stents in Lung Transplant Recipients.

Bronchial stenosis is a common complication following lung transplantation. We evaluated long-term associations of the use of self-expandable metal stents (SEMSs) with lung function tests, patient safety, and survival. A retrospective chart review of 582 lung transplantations performed at our institution between January 2002 and January 2018. Fifty-four patients with SEMSs (intervention group) were matched one-to-one to patients without SEMSs (control group) using propensity score matching for age, sex, the year, and type of transplantation (unilateral/bilateral), and underlying disease. Data regarding long-term lung function and survival were compared between the groups. During a median follow-up of 54.8 months, the difference in survival between the study groups was not statistically significant (p = 0.2). Following 5, 7.5 and 10 years, values of mean forced expiratory volume in 1 second (FEV1) were comparable between patients with and without SEMSs as follows: 59.5 versus 62.6% (p = 0.2), 55.9 versus 55.0% (p = 0.4), and 63.5 versus 61.9% (p = 0.3), respectively. In the intervention group, a significant increase in the mean FEV1 was observed in 60 days after stent insertion (from 41.9 ± 12.8 to 49.5 ± 16.7% days, p < 0.001). Long-term complications following stent insertion included severe bleeding (1.8%), stent fractures (7.4%), stent stenosis (7.4%), stent collapse (3.7%), endobronchial pressure ulcer (1.9%), and stent migration (1.9%). SEMS insertion is associated with a positive sustained effect on lung function, without increasing long-term mortality. Thus, airway stenosis after lung transplantation can be safely and successfully treated using endobronchial metal stenting, with tight bronchoscopic follow-up and maintenance.

Bile aspiration during EUS-guided hepaticogastrostomy is associated with lower risk of postprocedural adverse events: a retrospective single-center study.

In endoscopic retrograde cholangiopancreatography (ERCP), reduction of pressure inside of the bile duct by bile aspiration is a well-known method to lower the rate of adverse events (AEs) including cholangitis. Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) has been introduced as an alternative to ERCP. The use of self-expandable metallic stents is recommended in EUS-HGS to reduce bile leak; however, other methods to reduce the rate of AEs including bile leak, abdominal pain, fever, and sepsis, have not been elucidated yet. This study investigated whether bile aspiration during EUS-HGS decreased the rate of postprocedural AEs. Consecutive patients who underwent EUS-HGS between July 2016 and April 2020 were retrospectively evaluated in this study. EUS-HGS was performed at a tertiary cancer center. Patient characteristics, site of biliary obstruction, the quantity of bile aspirated during EUS-HGS, type of stent, whether or not antegrade stenting (AS) was performed, procedure time, and AEs were assessed based on a prospectively recorded institutional endoscopy database. Logistic regression analysis was performed to identify factors affecting postprocedural AEs. Ninety-six patients were included in the study. EUS-guided HGS with and without AS was performed in 45 and 51 patients, respectively. Bile was aspirated in 71 patients (74%). The quantity of bile aspirated was 0-10mL and > 10mL in 40 and 56 patients, respectively. AEs including fever, abdominal pain, postprocedural cholangitis, sepsis, acute pancreatitis, and bleeding occurred in 45 patients (47%). The AE rates were 65% (26/40) and 34% (19/56), for 0-10mL and > 10mL bile, respectively (p = 0.004). Using multivariate analysis, the only independent factor affecting the occurrence of AEs was found to be an aspirated bile amount of 0-10mL (odds ratio: 4.16; 95% CI 1.6-10.8). Bile aspiration of more than 10mL during EUS-HGS contributes to reducing the rate of postprocedural AEs.

“Stent in Stent” Procedure for Treatment of Extreme Strictures of Colorectal Cancer – Case Series in a Single Center: How to Do it

Background: Since 1990’s the use of self-expanding metal stent has been known. Initially, this kind of technique has been debated in literature. Actually, is a widely used technique for treatment of bowel neoplastic obstruction. This procedure is important to restore bowel canalization but is feasible performed by expert endoscopists and a dedicated anesthesiologist team. More difficult seems to be the treatment of strictures longer than 9 cm of large bowel or synchronous very close stenosis of rectal-sigmoid junction and rectum. This technical note demonstrated how SEMS positioning can be performed for treatment of long and extreme large bowel obstruction. Methods: In this case series we have treated all patients admitted in our department with diagnosis of extreme bowel neoplastic obstruction, with “stent in stent” technique, in deep sedation. Results: From January to August 2019 we admitted in our Surgical and Endoscopic Unit two patients, a 90- year-old for bowel obstruction by synchronous colorectal cancer and a 80-year-old female for 15 cm large bowel neoplastic obstruction. Patients were submitted to “Stent-in-Stent” technique. No complications and perforation were observed with restore of bowel canalization after few hours from SEMS positioning. Both patients had no signs of bowel obstruction at abdomen X-Ray control, after 48 hours. 80-year-old female patient was submitted to left colectomy after 6 days without complications, while 90-year-old was discharge after 3 days. Conclusion: This study demonstrated how is possible to perform endoscopic SEMS positioning to treat longer than 15 cm neoplastic large bowel obstruction and synchronous colorectal cancer with “Stent-inStent” technique. Our technical note describes, point by point, all passages of this procedure and suggests as is possible to treat synchronous sigmoid-rectal neoplastic obstruction using two different kind of metal stent.