Biliary and pancreatic stenting:Devices and insertiontechniques in therapeutic endoscopic retrogradecholangiopancreatography and endoscopic ultrasonography

Stents are tubular devices made of plastic or metal. Endoscopic stenting is the most common treatment for obstruction of the common bile duct or of the main pancreatic duct, but also employed for the treatment of bilio-pancreatic leakages, for preventing post- endoscopic retrograde cholangiopancreatography pancreatitis and to drain the gallbladder and pancreatic fluid collections. Recent progresses in techniques of stent insertion and metal stent design are represented by new, fullycovered lumen apposing metal stents. These stents are specifically designed for transmural drainage, with a saddle-shape design and bilateral flanges, to provide lumen-to-lumen anchoring, reducing the risk of migration and leakage. This review is an update of the technique of stent insertion and metal stent deployment, of the most recent data available on stent types and characteristics and the new applications for biliopancreatic stents.

Treating bilio-duodenal obstruction: Combining new endoscopic technique with 6 Fr stent introducer

Periampullary cancer may cause not only biliary but also duodenal obstructions. In patients with concomitant duodenal obstructions, endoscopic biliary stenting remains technically difficult and may often require percutaneous transhepatic biliary drainage. We describe a method of metal stent placement via a thin forwardviewing endoscope in patients with simultaneous biliary and duodenal obstruction. In two consecutive patients with biliary and duodenal obstruction due to pancreatic cancer, a new biliary metal stent mounted in a slim delivery catheter was placed via a thin forward viewing endoscope after passage across the duodenal stenosis without balloon dilation. In both patients, with our new placement technique, metallic stents were successfully placed in a short time without adverse events. After biliary stenting, one patient received curative resection and the other received duodenal stenting for palliation. Metallic stent placement with a forward-viewing thin endoscope is a beneficial technique, which can avoid percutaneous drainage in patients with bilio-duodenal obstructions due to periampullary cancer.

Feasibility and safety of using Soehendra stent retriever as a new technique for biliary access in endoscopic ultrasoundguided biliary drainage

AIM:To assess the feasibility and safety of the use of soehendra stent retriever as a new technique for biliary access in endoscopic ultrasound-guided biliary drainage.METHODS:The medical records and endoscopic reports of the patients who underwent endoscopic ultrasound-guided biliary drainage(EUS-BD) owing to failed endoscopic retrograde cholangiopancreatography in our institute between June 2011 and January 2014 were collected and reviewed.All the procedures were performed in the endoscopic suite under intravenous sedation with propofol and full anaesthetic monitoring.Then we used the Soehendra stent retriever as new equipment for neo-tract creation and dilation when performing EUS-BD procedures.The patients were observed in the recovery room for 1-2 h and transferred to the regular ward,patients' clinical data were reviewed and analysed,clinical outcomes were defined by using several different criteria.Data were analysed by using SPSS 13 and presented as percentages,means,and medians.RESULTS:A total of 12 patients were enrolled.The most common indications for EUS-BD in this series were failed common bile duct cannulation,duodenal obstruction,failed selective intrahepatic duct cannulation,and surgical altered anatomy for 50%,25%,16.7%,and 8.3%,respectively.Seven patients underwent EUS-guided hepaticogastrostomy(58.3%),and 5 underwent EUS-guided choledochoduodenostomy(41.7%).The technical success rate was 100%,while the clinical success rate was 91.7%.Major and minor complications occurred in 16.6% and 33.3% of patients,respectively,but there were no procedurerelated death.CONCLUSION:Soehendra stent retriever could be used as an alternative instrument for biliary access in endoscopic ultrasound guided biliary drainage.

Management of chronic dacryocystitis cases after failed external dacryocystorhinostomy using endoscopic technique with a novel lacrimal ostium stent

AIM: To demonstrate the outcomes of endoscopic endonasal dacryocystorhinostomy(En-DCR) with an novel lacrimal ostium stent(LOS) which was performed in patients with recurrent epiphora after failed external dacryocystorhinostomy(Ex-DCR) and analyze the causes of failed Ex-DCR.METHODS: From September 2015 and December 2017, the clinic data of 29 cases suffered from recurrent epiphora after failed Ex-DCR was reviewed.The LOS were implanted into the ostium at the end of the revisional surgery.The causes of failed Ex-DCR were analyzed before revisional surgeries.Outcome of revisional surgeries with the new device were evaluated as well.RESULTS: The major causes of failure of the external approach were synechiae formation in the nasal ostium(29/29), followed by inadequate removal of the bony wall(21/29), nasal synechiae formation between lateral wall of nose and middle turbinate(11/29), and the bone opening was not in good location(7/29).The rate of success after revisional surgery was 82.76%.Re-obstruction of the ostiums were found in 5 failed cases.CONCLUSION: Endoscopic approach with a novel LOS may be an effective procedure to manage recurrent epiphora after previous failed Ex-DCR surgery.Synechiae formation in the nasal ostium and inadequate removal of the bony wall were the major causes of failure of Ex-DCR.

Implantation of trabecular micro-bypass stent using a novel “landing strip” technique

AIM：To describe a novel technique of creating a landing strip within the trabecular meshwork to guide trabecular micro-bypass stent（iStent） implantation in patients who underwent phacoemulsification.METHODS：Thirty-four eyes from 30 patients who underwent i Stent implantation after phacoemulsification from May 2014 to February 2015 were included in our retrospective study. All iStents were implanted via the ＂landing strip＂ technique. A 25-gauge microvitreoretinal blade was used to bisect the trabecular meshwork to less than 1 clock-hour, effectively creating a landing strip. The iStent applicator was pressed along the landing strip and then the stent was released into the trabecular meshwork. RESULTS：Of the 34 eyes with iStent implantation, 27（79.4%） eyes had primary open-angle glaucoma, 6（17.6%） eyes had pseudoexfoliation glaucoma, and 1（2.9%） eye had ocular hypertension. At 6-month follow-up（n=17）, the mean number of hypotensive medications decreased from 2.2±1.2 at baseline to 0.8±1.3（P=0.05） and mean intraocular pressure decreased from 19.7±4.1 mm Hg at baseline to 16.7±2.1 mm Hg（P=0.58）. Two eyes（5.9%） required subsequent trabeculectomy. CONCLUSION：The ＂landing strip＂ technique appears to be an effective way to assist with iS tent implantation.

Effect of Time, Cultivar and Rootstock on Success of Rose Propagation through Stenting Technique

An experiment was undertaken to study the effects of two grafting times (1st of June and end of September) as well as kind of rootstock on growth and rooting of rose stentlings. Two Rosa species i.e. R. canina and R. manetti were selected as rootstock and three different hybrid tea rose cultivars namely Avalanch, Peach Avalanch and Dolcevita were grafted on them as scion through omega and splice techniques. The growth parameters were collected 57 days after grafting. The highest average of rooting, healing percentage, numbers of root, shoot and leaves were seen in September grafted plants. In overall Rosa canina was the best rootstock for Avalanch cultivar. Other observations did not lead to any prominent result as it varied with time of grafting, scion and rootstock cultivars.

Brachial access technique for aortoiliac stenting revisited

We report a modified technique to perform iliac artery stenting through the brachial artery access. A 6F Brite tip sheath (Cordis, Jonhson & Jonhson Medical, Miami Lakes, FL, USA) is inserted into either brachial artery and a standard 4F Judkins Right diagnostic catheter was inserted over a 260 cm 0.038” Terumo Stiff wire (Terumo Corp, Tokyo, Japan) through the sheath. The catheter is navigated down to the aortic bifurcation, and after selecting the common iliac artery ostium, the wire is navigated through the lesion and advanced to the ipsilateral superficial femoral arteries. The catheter should be then moved forward over the wires beyond the lesion and the Terumo guidewire is replaced by two 0.038” 260 cm Supracor wires (Boston Scientific Corporation, San Jose, CA, USA). In order to facilitate advancement of the stent without risk of dislodgement as well as to check the position with low contrast dose injection, a 6 F (or 7F if large stent is selected) 90cm Shuttle Flexor introducer long sheath (Cook Group, Bloomington, IN, USA) should be advanced over the Supracor wire until it reaches the common iliac artery ostium. A road-map technique can be used to check the ostium position in order to properly deploy the selected stent. This technique promises to be safe and effective offering more support than guiding catheter technique; moreover it reduces the stress on the arterial vessel at the subclavian site and enables a stiff balloon or stent catheter to be advanced even through a very elongated and calcified aorta without the risk of stent dislodgement.

Revision of bilateral self-expandable metallic stents placed using the stent-in-stent technique for malignant hilar biliary obstruction

Background: Endoscopic biliary decompression using bilateral self-expandable metallic stent(SEMS) placed using the stent-in-stent(SIS) technique is considered favorable for unresectable malignant hilar biliary obstruction(MHBO). However, occlusion of the bilateral SIS placement is frequent and revision can be challenging. This study was performed to investigate the efficacy, the long-term patency and the appropriate approach for revision of occluded bilateral SIS placement in unresectable MHBO. Methods: From January 2011 to July 2016, thirty-eight patients with unresectable MHBO underwent revision of occluded bilateral SIS placement. Clinical data including success rates and patency of revision, were retrospectively analyzed. Results: The technical success rate of revision was 76.3%. The clinical success rate of revision was 51.7% and mean patency of revision was 49.1 days. No significant predictive factor for clinical failure of revision was observed. The cell size of SEMS was not found to have significant effects on clinical success rates or revision patency. Conclusions: Revision of occluded bilateral SIS placement for MHBO showed fair patency and clinical success rate. Revision method and cell size of SEMS were not found to influence clinical outcomes.

Fluoroscopic removal of fractured,retained,embedded Z self-expanding metal stent using a guidewire lasso technique:A case report

BACKGROUND There are few reports of a fractured esophageal self-expanding metallic stent(SEMS)and the lasso retrieval technique,forming a guidewire loop by directing the guidewire back up the external stent for retrieval.CASE SUMMARY A 74-year-old man complained of dysphagia approximately 6 mo after radical resection of esophageal cancer.Benign anastomotic stenosis was diagnosed,and a 20 mm in diameter and 60 mm in length esophageal covered SEMS was inserted after repeated balloon dilatation.About 13.5 mo after stenting,dysphagia recurred and esophagography showed severe stenosis above the proximal stent and stent removal was performed.One-third of the stent was removed and the fractured stent remained in the proximal esophagus.A suction tube was introduced through the guidewire and then the guidewire was grabbed,acting like a“lasso”on tightening.The remaining fractured stent was successfully removed by slowly pulling back the guidewire,with no fragments of stent wires retained.CONCLUSION The guidewire lasso technique is a simple,effective method of removing esophageal SEMS in rare cases of stent fracture.

Role of Grafting Technique on the Success of Stenting Propagation of Two Rose (<i>Rosa</i>sp.) Varieties

The influence of two grafting techniques on the success of stenting (simultaneous cutting and grafting) and some ensuing growth parameters of stentlings were studied under glasshouse conditions. The Avalanch and Peach Avalanch glasshouse rose varieties were utilized as scion and grafted on R. manetti as rootstock. Two grafting techniques namely, splice and omega grafting methods were practiced and graft combinations were inserted in cocopeat-perlit (1:2) medium under mist system. The number of roots, longest root size, shoots and leaf numbers and successful grafting percentage were evaluated after grafting. In Avalanch/R. manetti and Peach Avalanch/R. manetti combinations, higher percentage of successful grafting was observed in the stentlings propagated via omega grafting technique. Furthermore Avalanch/R. manetti stentlings prepared by omega grafting were found to produce more number of roots, shoots and leaves and longest root size as compared to those propagated through splice grafting method. In case of Peach Avalanch/R. manetti combinations propagated via omega grafting more number of shoots was observed as compared to those propagated by splice method. However, these were not significantly different with respect to their leaf numbers. The results showed the superiority of omega grafting procedure.

Removal of an embedded "covered" biliary stent by the "stent-in-stent" technique

A 46-year-old man was admitted with obstructive jaundice and cross-sectional imaging with computed tomography suggested distal biliary obstruction.A distal common bile duct stricture was found at endoscopic retrograde cholangiopancreatography(ERCP)and cytology was benign.A 6 cm fully covered self-expanding metal stent(SEMS)was inserted across the stricture to optimize biliary drainage.However,the SEMS could not be removed at repeat ERCP a few months later.A further fully covered SEMS was inserted within the existing stent to enable extraction and both stents were retrieved successfully a few weeks later.Fully covered biliary(SEMS)are used to treat benign biliary strictures.This is the first reported case of inability to remove a fully-covered biliary SEMS.Possible reasons for this include tissue hyperplasia and consequent overgrowth into the stent proximally,or chemical or mechanical damage to the polymer covering of the stent.Application of the stent-in-stent technique allowed successful retrieval of the initial stent.

Successful stent-in-stent dilatation of the common bile duct through a duodenal prosthesis,a novel technique for malignant obstruction:A case report and review of literature

For patients suffering from both biliary and duodenal obstruction,endoscopic retrograde cholangiopancreatography(ERCP) with stent placement is the treatment of choice.ERCP through an already existing duodenal prosthesis is an uncommon procedure and furthermore no studies have reported installing a covered metal stent onto an already existing bare metal stent in the common bile duct(CBD).We describe a rare case of a stent-in-stent dilatation of the CBD through an already existing self-expanding metal stent in the second part of duodenum for the patient presenting with jaundice in setting of biliary and duodenal obstruction from pancreatic adenocarcinoma.The biliary obstruction was relieved with a decrease in bilirubin levels post-stenting.

Anchor-wire technique for multiple plastic biliary stents to prevent stent dislocation

In endoscopic placement of multiple plastic biliary stents (PBSs),we sometimes experience proximal dislocation of the first PBS at the time of subsequent PBS insertion.We describe the case of a 79-year-old male with obstructive jaundice caused by cholangiocarcinoma who needed to receive multiple PBS placements for management of cholangitis.Although proximal dislocation of the first PBS was observed,we prevented the dislocation via our technique of using guidewire inserted from the distal end of the first PBS to the side hole as the anchor-wire.We could complete this technique only by inserting guidewire through the side hole of the first PBS during the process of releasing the first PBS and pulling out the guidewire and the inner sheath.It did not matter whether the anchor-wire went towards the third portion of the duodenum or the duodenal bulb.Here we introduce this "anchor-wire technique",which is useful for the prevention of PBS proximal dislocation in placing multiple PBSs.

Modified Technique for Internal Ureteroileal Stenting in Orthotopic Neobladders

We introduce a modified surgical technique for internal ureteroileal stenting to improve cosmesis in patients undergoing ileal neobladder. Internal ureteric stents are secured to the tip of the urethral catheter with nonabsorbable suture facilitating removal of the stents postoperatively 2-3 weeks along with the urethral catheter. This surgical modification was applied to 21 patients of whom no significant surgical or infectious complication due to single urethral catheter was observed. Internal ureteral stenting is simple, safe and inexpensive alternative to conventional methods to support ureteroileal anastomosis in patients undergoing orthotopic bladder substitution.

Utility of the balloon-overtube-assisted modified over-thewire stenting technique to treat post-sleeve gastrectomy complications

AIM To describe a modified technique of deployment of stents using the overtube developed for balloonassisted enteroscopy in post-sleeve gastrectomy(SG) complications. METHODS Between January 2010 and December 2015, all patients submitted to an endoscopic stenting procedure to treat a post-SG stenosis or leakage were retrospectively collected. Procedures from patients in which the stent was deployed using the balloon-overtube-assisted modified over-the-wire(OTW) stenting technique were described. The technical success, corresponding to proper placement of the stent in the stomach resulting in exclusion of the SG leak or the stenosis, was evaluated. Complications related to stenting were also reported.RESULTS Five procedures were included to treat 2 staple line leaks and 3 stenoses. Two types of stents were used, including a fully covered self-expandable metal stent designed for the SG anatomy(Hanarostent, ECBB-30-240-090; M.I. Tech, Co., Ltd, Seoul, SouthKorea) in 4 procedures and a biodegradable stent(BD stent 019-10A-25/20/25-080, SX-ELLA, Hradec Kralove, Czech Republic) in the remaining procedure. In all cases, an overtube was advanced with the endoscope through the SG to the duodenum. After placement of the guidewire and removal of the endoscope, the stent was easily advanced through the overtube. The overtube was pulled back and the stent was successfully deployed under fluoroscopic guidance. Technical success was achieved in all patients.CONCLUSION The adoption of a modified technique of deployment of OTW stents using an overtube may represent an effective option in the approach of SG complications.

A Novel guide extension assisted stenting technique for coronary bifurcation lesions

A challenging technical scenario frequently encountered in a percutaneous coronary intervention of a coronary bifurcation lesion(CBL)is stent implantation of only the stenosed segment without compromising the other two normal segments in non-true bifurcation lesions.Another is precise stent implantation covering the side branch ostium without leaving excessive stent metal at the other two segments of a bifurcation lesion in complex true bifurcation lesions.The aim of this study was to describe a novel stenting technique for both non-true and true CBLs by using a guide extension catheter(GuideLiner).With the assistance of a guide extension catheter mounted on both the main and the side-branch guidewires and with its intubation down to the bifurcation carina,a stent can be implanted in the side branch segment or distal main segment of the bifurcation lesion appropriately without compromising the other two segments of the coronary bifurcation.Stent implantation is described in three bifurcation lesions in three cases and shown in detail with illustrative figures.The technique facilitates side-branch only stenting in side-branch mono-ostial(medina 0,0,1)CBL or only the distal main segment in distal mono-ostial(medina 0,1,0)CBL without compromising the other two remaining segments when using the onestent technique in non-true CBLs without leaving unnecessary excessive stent metal at the bifurcation site and when using a two-stent technique in complex true bifurcation lesions(tri-ostial or medina 1,1,1).Consequently,through optimizing stent deployment,the technique may have the potential to reduce the risk of subacute stent thrombosis and future in-stent restenosis.The most appropriate lesions suitable for the technique,and some other practical tips are also described.

Stent fracture after transjugular intrahepatic portosystemic shunt placement using the bare metal stent/stent-graft combination technique

BACKGROUND A transjugular intrahepatic portosystemic shunt(TIPS)is widely placed to treat portal hypertension.Because the Viatorr®stent(W.L.Gore and Associates,Flagstaff,AZ,United States)is not available in all hospitals in China,the bare metal stent(BMS)/stent-graft combination technique is still popular for TIPS construction.Stent fracture is a complication after TIPS placement using this technique,with limited available literature focusing on it.AIM To assess the incidence of stent fracture after TIPS placement using the BMS/stent-graft combination technique and to identify the risk factors for stent fracture.We proposed technique modifications to improve the clinical results of TIPS placement with the BMS/stent-graft combination technique.METHODS We retrospectively analyzed the computed tomography(CT)data of all patients with portal hypertension who underwent the TIPS procedure between June 2011 and December 2021 in a single center.Patients implanted with the BMS/stent graft and had follow-up imaging data available were included.We identified patients with stent fracture and analyzed their characteristics.Multivariable logistic regression was applied to identify the potential predictors of stent fracture.RESULTS Of the 68 included patients,stent fracture occurred in seven(10.3%)patients.Based on CT images,the stent fractures were categorized into three types.Our study consisted of four(57.1%)type I fractures,one(14.3%)type II fracture,one(14.3%)type IIIa fracture,and one(14.3%)type IIIb fracture.After adjusting for covariates,multivariable logistic regression revealed that the risk factors for stent fracture were the implantation of a greater number of stents[adjusted odds ratio(aOR)=22.2,95%confidence interval(CI):1.2-415.4,P=0.038]and a larger proximal sagittal stent bending angle(aOR=1.1,95%CI:1.0-1.3,P=0.020).CONCLUSION Stent fracture occurred in approximately 10%of patients with portal hypertension who underwent TIPS with the BMS/stent-graft combination technique.The number of implanted stents and stent bending angle at the inferior vena cava end were predictors of stent fracture,which suggests that the incidence of stent fracture could potentially be reduced by procedural modifications.

The clinical study of modified total aortic arch replacement and stent elephant trunk technique treatment for patients with DeBakey Ⅰ thoracic aortic dissection

Objective To summarize the clinical study of modified total aortic arch replacement and stent elephant trunk technique treatment to patients with DeBakey Ⅰ thoracic aortic dissection. Methods From January 2006 to October 2010,101 cases of DeBakeyⅠaortic dissection were treated by modified total arch replacement and stent elephant trunk technique,in which emergencey surgery were performed on 73 cases. There were 76 male and 25

Unloading and successful treatment with bioresorbable stents during percutaneous coronary intervention:A case report

BACKGROUND With the development of percutaneous coronary intervention(PCI),the number of interventional procedures without implantation,such as bioresorbable stents(BRS)and drug-coated balloons,has increased annually.Metal drug-eluting stent unloading is one of the most common clinical complications.Comparatively,BRS detachment is more concealed and harmful,but has yet to be reported in clinical research.In this study,we report a case of BRS unloading and successful rescue.This is a case of a 59-year-old male with the following medical history:“Type 2 diabetes mellitus”for 2 years,maintained with metformin extended-release tablets,1 g PO BID;“hypertension”for 20 years,with long-term use of metoprolol sustained-release tablets,47.5 mg PO QD;“hyperlipidemia”for 20 years,without regular medication.He was admitted to the emergency department of our hospital due to intermittent chest pain lasting 18 hours,on February 20,2022 at 15:35.Electrocardiogram results showed sinus rhythm,ST-segment elevation in leads I and avL,and poor R-wave progression in leads V1–3.High-sensitivity troponin I level was 4.59 ng/mL,indicating an acute high lateral wall myocardial infarction.The patient’s family requested treatment with BRS,without implanta-tion.During PCI,the BRS became unloaded but was successfully rescued.The patient was followed up for 2 years;he had no episodes of angina pectoris and was in generally good condition.CONCLUSION We describe a case of a 59-year-old male experienced BRS unloading and successful rescue.By analyzing images,the causes of BRS unloading and the treatment plan are discussed to provide insights for BRS release operations.We discuss preventive measures for BRS unloading.

Endoscopic-ultrasound-guided biliary drainage with placement of electrocautery-enhanced lumen-apposing metal stent for palliation of malignant biliary obstruction:Updated meta-analysis

BACKGROUND Endoscopic ultrasound-guided biliary drainage using electrocautery-enhanced(ECE)delivery of lumen-apposing metal stent(LAMS)is gradually being re-cognized as a viable palliative technique for malignant biliary obstruction after endoscopic retrograde cholangiopancreatography(ERCP)failure.However,most of the studies that have assessed its efficacy and safety were small and hetero-geneous.Prior meta-analyses of six or fewer studies that were published 2 years ago were therefore underpowered to yield convincing evidence.AIM To update the efficacy and safety of ECE-LAMS for treatment of biliary ob-struction after ERCP failure.METHODS We searched PubMed,EMBASE,and Scopus databases from the inception of the ECE technique to May 13,2022.Primary outcome measure was pooled technical success rate,and secondary outcomes were pooled rates of clinical success,re-intervention,and adverse events.Meta-analysis was performed using a random-effects model following Freeman-Tukey double-arcsine transformation in R soft-ware(version 4.1.3).RESULTS Fourteen eligible studies involving 620 participants were ultimately included.The pooled rate of technical success was 96.7%,and clinical success was 91.0%.Adverse events were reported in 17.5%of patients.Overall reinter-vention rate was 7.3%.Subgroup analyses showed results were generally consistent.CONCLUSION ECE-LAMS has favorable success with acceptable adverse events in relieving biliary obstruction when ERCP is impossible.The consistency of results across most subgroups suggested that this is a generalizable approach.