Predictive factors for the failure of endoscopic stent-instent self-expandable metallic stent placement to treat malignant hilar biliary obstruction

AIM To investigate the factors predictive of failure when placing a second biliary self-expandable metallic stents(SEMSs). METHODS This study evaluated 65 patients with an unresectable malignant hilar biliary obstruction who were examined in our hospital. Sixty-two of these patients were recruited to the study and divided into two groups: the success group, which consisted of patients in whom a stent-in-stent SEMS had been placed successfully, and the failure group, which consisted of patients in whom the stent-in-stent SEMS had not been placed successfully. We compared the characteristics of the patients, the stricture state of their biliary ducts, and the implemented endoscopic retrograde cholangiopancreatography(ERCP) procedures between the two groups.RESULTS The angle between the target biliary duct stricture and the first implanted SEMS was significantly larger in the failure group than in the success group. There were significantly fewer wire or dilation devices(ERCP catheter, dilator, or balloon catheter) passing the first SEMS cell in the failure group than in the success group. The cut-off value of the angle predicting stent-in-stent SEMS placement failure was 49.7 degrees according to the ROC curve(sensitivity 91.7%, specificity 61.2%). Furthermore, the angle was significantly smaller in patients with wire or dilation devices passing the first SEMS cell than in patients without wire or dilation devices passing the first SEMS cell. CONCLUSION A large angle was identified as a predictive factor for failure of stent-in-stent SEMS placement.

Self-expanding metallic stents drainage for acute proximal colon obstruction

AIM: To clarify the usefulness of the self-expanding metallic stents (SEMS) in the management of acute proximal colon obstruction due to colon carcinoma before curative surgery.METHODS: Eighty-one colon (proximal to spleen flex) carcinoma patients (47 males and 34 females,aged 18-94 years,mean = 66.2 years) treated between September 2004 and June 2010 for acute colon obstruction were enrolled to this study,and their clinical and radiological features were reviewed.After a cleaning enema was administered,urgent colonoscopy was performed.Subsequently,endoscopic decompression using SEMS placement was attempted.RESULTS: Endoscopic decompression using SEMS placement was technically successful in 78 (96.3%) of 81 patients.Three patients’ symptoms could not be relieved after SEMS placement and emergent operation was performed 1 d later.The site of obstruction was transverse colon in 18 patients,the hepatic flex in 42,and the ascending colon in 21.Following adequate cleansing of the colon,patients’ abdominal girth was decreased from 88 ± 3 cm before drainage to 72 ± 6 cm 7 d later,and one-stage surgery after 8 ± 1 d (range,7-10 d) was performed.No anastomotic leakage or postoperative stenosis occurred after operation.CONCLUSION: SEMS placement is effective and safe in the management of acute proximal colon obstruction due to colon carcinoma,and is considered as a bridged method before curative surgery.

One-step palliative treatment method for obstructive jaundice caused by unresectable malignancies by percutaneous transhepatic insertion of an expandable metallic stent

AIM： To describe a simple one-step method involving percutaneous transhepatic insertion of an expandable metal stent （EMS） used in the treatment of obstructive jaundice caused by unresectable malignancies. METHODS： Fourteen patients diagnosed with obstructive jaundice due to unresectable malignancies were included in the study. The malignancies in these patients were a result of very advanced carcinoma or old age. Percutaneous transhepatic cholangiography was performed under ultrasonographic guidance. After a catheter with an inner metallic guide was advanced into the duodenum, an EMS was placed in the common bile duct, between a point 1 cm beyond the papilla of Vater and the entrance to the hepatic hilum. In cases where it was difficult to span the distance using just a single EMS, an additional stent was positioned. A drainage catheter was left in place to act as a hemostat. The catheter was removed after resolution of cholestasis and stent patency was confirmed 2 or 3 d post-procedure. RESULTS： One-step insertion of the EMS was achieved in all patients with a procedure mean time of 24.4 min. Out of the patients who required 2 EMS, 4 needed a procedure time exceeding 30 min. The mean time for removal of the catheter post-procedure was 2.3 d. All patients died of malignancy with a mean follow-up time of 7.8 mo. No stent-related complication or stent obstruction was encountered. CONCLUSIONS： One-step percutaneous transhepaticinsertion of EMS is a simple procedure for resolving biliary obstruction and can effectively improve the patient＇s quality of life.

Clinical benefit of radiation therapy and metallic stenting for unresectable hilar cholangiocarcinoma

AIM： To determine the efficacy of external beam radiotherapy （EBRT）, with or without intraluminal brachytherapy （ILBT）, in patients with non-resected locally advanced hilar cholangiocarcinoma.METHODS： We analyzed 64 patients with locally advanced hilar cholangiocarcinoma, including 25 who underwent resection （17 curative and 8 non-curative）, 28 treated with radiotherapy, and 11 who received best supportive care （BSC）. The radiotherapy group received EBRT （50 Gy, 30 fractions）, with 11 receiving an ad- ditional 24 Gy （4 fractions） ILBT by iridium-192 with remote after loading. ILBT was performed using percu-taneous transhepatic biliary drainage （PTBD） route. Uncovered metallic stents （UMS） were inserted into nonresected patients with obstructive jaundice, with the exception of four patients who received percutaneous transhepatic biliary drainage only. UMS were placed endoscopically or percutaneously, depending on the initial drainage procedure. The primary endpoints were patient death or stent occlusion. Survival time of patients in the radiotherapy group was compared with that of patients in the resection and BSC groups. Stent patency was compared in the radiotherapy and BSC groups.RESULTS： No statistically significant differences in patient characteristics were found among the resection, radiotherapy, and BSC groups. Three patients in the radiotherapy group and one in the BSC group did not receive UMS insertion but received PTBD alone; cholangitis occurred after endoscopic stenting, and patients were treated with PTBD. A total of 16 patients were administered additional systemic chemotherapy （5-fluorouracil-based regimen in 9, S-1 in 6, and gemcitabine in 1）. Overall survival varied significantly among groups, with median survival times of 48.7 mo in the surgery group, 22.1 mo in the radiotherapy group, and 5.7 mo in the BSC group. Patients who underwent curative resection survived significantly longer than those who were not candidates for surgery （P = 0.0076）. Cumulative survival in the radiotherapy group was significantly longer than in the BSC group （P = 0.0031）, but did not differ significantly from those in the non-resection group. Furthermore, the median survival time of patients in the radiotherapy group who were considered for possible resection （excluding the seven patients who were not candidates for surgery due to comorbid disease or age） was 25.9 mo. Stent patency was evaluated only in the 24 patients who received a metallic stent. Stent patency was significantly longer in the radiotherapy than in the BSC group （P = 0.0165）. Biliary drainage was not eliminated in any patient. To determine the efficacy of ILBT, we compared

Temporary self-expanding metallic stents for achalasia: A prospective study with a long-term follow-up

AIM: To compare the efficacy of self-expanding metallic stents (SEMSs) for the long-term clinical treatment of achalasia. METHODS: Ninety achalasic patients were treated with a temporary SEMS with a diameter of 20 mm (n = 30, group A), 25 mm (n = 30, group B) or 30 mm (n = 30, group C). Data on clinical symptoms, complications and treatment outcomes were collected, and follow-up was made at 6 mo and at 1, 3-5, 5-8, 8-10 and > 10 years, postoperatively.RESULTS: Stent placement was successful in all patients. Although chest pain occurrence was high, stent migration was less in group C than in groups A and B. The clinical remission rate at 5-8, 8-10 and > 10 years in group C was higher than that in the other two groups. The treatment failure rate was lower in group C (13%) than in groups A (53%) and B (27%). SEMSs in group C resulted in reduced dysphagia scores and lowered esophageal sphincter pressures, as well as normal levels of barium height and width during all the follow-up time periods. Conversely, these parameters increased over time in groups A and B. The primary patency in group C was longer than in groups A and B. CONCLUSION: A temporary SEMS with a diameter of 30 mm is associated with a superior long-term clinical efficacy in the treatment of achalasia compared with a SEMS with a diameter of 20 mm or 25 mm.

Self-expandable metallic stents for palliation of patients with malignant gastric outlet obstruction caused by stomach cancer

AIM: To ascertain clinical outcome and complications of self-expandable metal stents for endoscopic palliation of patients with malignant obstruction of the gastrointestinal (GI) tract. METHODS: A retrospective review was performed throughout August 2000 to June 2005 of 53 patients with gastric outlet obstruction caused by stomach cancer. All patients had symptomatic obstruction including nausea, vomiting, and decreased oral intake. All received self-expandable metallic stents. RESULTS: Stent implantation was successful in all 53 (100%) patients. Relief of obstructive symptoms was achieved in 43 (81.1%) patients. No immediate stent-related complications were noted. Seventeen patients had recurrent obstruction (tumor ingrowth in 14 patients, tumor overgrowth in 1 patient, and partial distal stent migration in 2 patients). The mean survival was 145 d. Median stent patency time was 187 d. CONCLUSION: Endoscopic placement of self-expandable metallic stents is a safe and effective treatment for the palliation of patients with inoperable malignant gastric outlet obstruction caused by stomach cancer.

Self-expandable metallic stents for malignant biliary obstruction:Efficacy on proximal and distal tumors

AIM： To compare the efficacy of self-expandable metallic stents （EMS） in the treatment of distal and proximal stricture of malignant biliary tumors. METHODS： From March 1995 to June 2004, 61 patients （40 males, 21 females） with malignant biliary obstruction who received self-expandable metallic stent implantation were reviewed retrospectively. The stents were inserted by an endoscopic or percutaneous transhepatic method. We tried to place two stents in the biliary system in T or Y configuration in cases of hilar tumors with bilateral hepatic duct obstruction. The end points of the study were stent occlusion or patient death. RESULTS： The mean time of stent patency was 421 ± 67 d in the group of proximal stricture（ group Ⅰ） and 168 ± 18 d in the group of distal stricture （group Ⅱ）. The difference was significant in borderline between the two groups （P = 0.0567）. The mean survival time was 574 ± 76 d in group I and 182 ± 25 d in group II. There was a significant difference between the two groups （P = 0.0005）. CONCLUSION： EMS implantation is a feasible, palliative method for unresectable malignant biliary obstruction. The clinical efficacy of EMS in patients with proximal hilar tumors is better than that in patients with distal tumors.

Long-term outcome of endoscopic metallic stenting for benign biliary stenosis associated with chronic pancreatitis

AIM： Endoscopic metal stenting （EMS） offers good results in short to medium term follow-up for bile duct stenosis associated wfth chronic pancreatitis （CP）; however, longer follow-up is needed to determine if EMS has the potential to become the treatment of first choice. METHODS： EMS was performed in eight patients with severe common bile duct stenosis due to CP. After the resolution of cholestasis by endoscopic naso-biliary drainage three patients were subjected to EMS while, the other five underwent EMS following plastic tube stenting. The patients were followed up for more than 5 years through periodical laboratory tests and imaging techniques. RESULTS： EMS was successfully performed in all the patients. Two patients died due to causes unrelated to the procedure： one with an acute myocardial infarction and the other with maxillary carcinoma at 2.8 and 5.5 years after EMS, respectively. One patient died with cholangitis because of EMS clogging 3.6 years after EMS. None of these three patients had showed symptoms of cholestasis during the follow-up period. Two patients developed choledocholithiasis and two suffered from duodenal ulcers due to dislodgement of the stent between 4.8 and 7.3 years after stenting; however, they were successfully treated endoscopically. Thus, five of eight patients are alive at present after a mean follow-up period of 7.4 years. CONCLUSION： EMS is evidently one of the very promising treatment options for bile duct stenosis associated with CP, provided the patients are closely followed up; thus setting a system for their prompt management on emergency is desirable.

Partial stent-in-stent placement of biliary metallic stents using a short double-balloon enteroscopy

Endoscopic intervention is less invasive than percutaneous or surgical approaches and should be considered the primary drainage procedure in most cases with obstructive jaundice.Recently,therapeutic endoscopic retrograde cholangiopancreatography(ERCP) using double-balloon enteroscopy(DBE) has been shown to be feasible and effective,even in patients with surgically altered anatomies.On the other hand,endoscopic partial stent-in-stent(PSIS) placement of selfexpandable metallic stents(SEMSs) for malignant hilar biliary obstruction in conventional ERCP has also been shown to be feasible,safe and effective.We performed PSIS placement of SEMSs for malignant hilar biliary obstruction due to liver metastasis using a short DBE in a patient with Roux-en-Y anastomosis and achieved technical and clinical success.This procedure can result in quick relief from obstructive jaundice in a single session and with short-term hospitalization,even in patients with surgically altered anatomies.

Safety and efficacy of self-expandable metallic stents in malignant small bowel obstructions

In this report, we present 3 cases of malignant small bowel obstruction, treated with palliative care using endoscopic self-expandable metallic stent(SEMS) placement, with the aim to identify the safety and efficacy of this procedure. Baseline patient characteristics, procedure methods, procedure time, technical and clinical success rates, complications, and patient outcomes were obtained. All 3 patients had pancreatic cancer with small bowel strictures. One patient received the SEMS using colonoscopy, while the other 2 patients received SEMS placement via double balloon endoscopy using the through-the-overtube technique. The median procedure time was 104 min. The technical and clinical success rates were 100%. Post-treatment, obstructive symptoms in all patients improved, and a low-residue diet could be tolerated. All stents remained within the patients until their deaths. The median overall survival time(stent patency time) was 76 d. SEMS placement is safe and effective as a palliative treatment for malignant small bowel obstruction.

Endoscopic ultrasound-guided choledochoduodenostomies with fully covered self-expandable metallic stents

AIM:To investigate the long-term outcomes of endoscopic ultrasound-guided choledochoduodenostomy(EUS-CDS) with a fully covered self-expandable metallic stent(FCSEMS).METHODS:From April 2009 to August 2010,15 patients with distal malignant biliary obstructions who were candidates for alternative techniques for biliary decompression due to a failed endoscopic retrograde cholangiopancreatography(ERCP) were included.These 15 patients consisted of 8 men and 7 women and had a median age of 61 years(range:30-91 years).The underlying causes of the distal malignant biliary obstruction were pancreatic cancer(n = 9),ampulla of Vater cancer(n = 2),renal cell carcinoma(n = 1),advanced gastric cancer(n = 1),lymphoma(n = 1),and duodenal cancer(n = 1).RESULTS:The technical success rate of EUS-CDS with an FCSEMS was 86.7%(13/15),and functional success was achieved in 100%(13/13) of those cases.In two patients,the EUS-CDS failed because an FCSEMS with a delivery device could not be passed into the common bile duct.The mean duration of stent patency was 264 d.Early adverse events developed in three patients(3/13,23.1%),including self-limited pneumoperitoneum in two patients and cholangitis requiring stent reposition in one patient.During the follow-up period(median:186 d,range:52-388 d),distal stent migration occurred in four patients(4/13,30.8%).In 3 patients,the FCSEMS could be reinserted through the existing choledochoduodenal fistula tract.CONCLUSION:EUS-CDS with an FCSEMS is technically feasible and can lead to effective palliation of distal malignant biliary obstructions after failed ERCP.

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.

Efficacy of uncovered self-expandable metallic stent for colorectal obstruction by extracolonic malignancy

BACKGROUND Self-expandable metallic stent(SEMS)is widely used for malignant colorectal obstruction.Recently,SEMS has been used for palliative option for colorectal obstruction caused by extracolonic malignancy(ECM).AIM To evaluate the efficacy of SEMS for colorectal obstruction caused by ECM,and to identify the factors associated with stent occlusion.METHODS Seventy-two patients who were treated with uncovered SEMS insertion for malignant colorectal obstructions caused by colorectal metastasis or peritoneal seeding of ECM at Samsung Medical Center between April 2012 to March 2016 were enrolled.We analyzed technical and clinical outcomes of stent insertion,the factors associated with stent occlusion and long term outcomes after stent insertion.RESULTS Technical success rate was determined as 90.3%with a clinical success rate of 87.7%.Stent occlusion developed in 28.1%,with a median duration of 51 d.Further,81.3%with stent occlusion could be treated with secondary stent insertion.Clinical failure was observed to be related to the male sex(P=0.020)and right colon obstruction(P=0.017).Stent length≤10 cm was found to be associated with stent occlusion(P=0.003).Median survival time after stent insertion was 4.7 mo and 40.4%were able to receive their oncological treatments after stent insertion without surgery.CONCLUSION Uncovered SEMS is effective for the treatment of colorectal obstruction caused by ECM,considering life expectancy of patients with ECM.

Effect of external beam radiotherapy on patency of uncovered metallic stents in patients with inoperable bile duct cancer

BACKGROUND： Although biliary decompression with metallic stenting is the preferred treatment for inoperable bile duct cancer（BDC）, maintenance of patency is still unsatisfactory.We tried to assess the effectiveness and safety of external beam radiotherapy（EBRT） for prolonging stent patency in patients having uncovered metallic stents.METHOD： We retrospectively reviewed 50 patients who received endoscopic stenting, of whom 18 received EBRT（RT group） and 32 did not（non-RT group）.RESULTS： No difference was found in baseline characteristics between the two groups. Although stent patency was longer in the RT group than that in the non-RT group（140.7±51.3 vs136.4±34.9 days, P=0.94）, the difference was not statistically significant. There were a lower rate of stent occlusion（27.8% vs50.0% of patients, P=0.12） and a longer overall survival（420.1 ±73.2 vs 269.1±41.7 days, P=0.11） in the RT group than in the non-RT group, and the difference again was not statistically significant. The development of adverse reactions did not differ（55.6% vs 53.1% of patients, P=0.91）. There was no serious adverse reaction in both groups（P=0.99）.CONCLUSIONS： EBRT did not significantly improve stent patency in patients with inoperable BDC having uncovered metallic stents. However, EBRT was safe. Future trials withrefined protocols for better efficacy are expected.

Removal of metallic stents using flexible bronchoscope:report of 29 cases

Objective:Placement of self expanding metallic stents(SEMS) is invariably associated with complications and often necessitates their removal usually by rigid bronchoscope.There have been few reports published on use of flexible bronchoscope(FB) for the removal.This article summarizes the indications,methods and complications of SEMS removal by FB.Methods:We reviewed our experience with removal of SEMS using FB retrospectively.The clinical data on 29 patients with average age of(39.0±13.2) years was analyzed who underwent removal of SEMS using FB between April 2002 and August 2008.Results:Thirty-seven procedures were performed in 29 consecutive patients to remove 37 stents.The average duration of stent placement was(55± 94.7) d(0-472 d).Twenty-two procedures(59.4%) were performed under local anesthesia.The percentage of procedures under general anesthesia was 13%(3/24),67%(4/6) and 100%(7/7) for the short-term(≤30 d),medium-term(31-90 d) and long-term(>90 d) of stents placement,respectively.Indications for stents removal included migration in 15(40.6%),scar restenosis in 11(29.7%),airway shaping in 5(13.5%),stent fracture in 2(5.4%),stent incomplete expansion in 2(5.4%),improper size in 1(2.7%),mucus plugging with chest pain in 1(2.7%).And 85.7% of long-term stents were removed due to scar restenosis.The total success rate was 92%.There was no significant difference in success rate between the uncovered and covered group(82.3% and 100%,P>0.05).Complications were encountered in 13 patients,bleeding being the most common(53.8%).Conclusion:Operation by FB may be an alternative method to remove SEMS effectively and safely based on the proper anesthesia chosen.

Angle of covered self-expandable metallic stents after placement is a risk factor for recurrent biliary obstruction

BACKGROUND Studies have shown that covered self-expandable metallic stents(CSEMS)with a low axial forces after placement can cause early recurrent biliary obstruction(RBO)due to precipitating sludge formation.AIM To ascertain whether the angle of CSEMS after placement is a risk factor for RBO in unresectable distal malignant biliary obstruction(MBO).METHODS Between January 2010 and March 2019,261 consecutive patients underwent selfexpandable metallic stent insertion by endoscopic retrograde cholangiopancreatography at our facility,and 87 patients were included in this study.We evaluated the risk factors for RBO,including the angle of CSEMS after placement as the primary outcome.We measured the obtuse angle of CSEMS after placement on an abdominal radiograph using the SYNAPSE PACS system.We also evaluated technical and functional success,adverse events,time to RBO(TRBO),non-RBO rate,survival time,cause of RBO,and reintervention procedure as secondary outcomes.RESULTS We divided the patients into two cohorts based on the presence or absence of RBO.The angle of CSEMS after placement(per 1°and per 10°)was evaluated using the multivariate Cox proportional hazard analysis,which was an independent risk factor for RBO in unresectable distal MBO[hazard ratio,0.97 and 0.71;95%confidence interval(CI):0.94-0.99 and 0.54-0.92;P=0.01 and 0.01,respectively].For early diagnosis of RBO,the cut-off value of the angle of CSEMS after placement using the receiver operating characteristic curve was 130°[sensitivity,50.0%;specificity 85.5%;area under the curve 0.70(95%CI:0.57-0.84)].TRBO in the<130°angle group was significantly shorter than that in the≥130°angle group(P<0.01).CONCLUSION This study suggests that the angle of the CSEMS after placement for unresectable distal MBO is a risk factor for RBO.These novel results provide pertinent information for future stent management.

Palliation of Malignant Esophageal Obstruction and Fistulas with Metallic Stents: A Tertiary Center Experience

Background: To determine the usefulness of metallic stent in advanced oesophageal malignancies. Methods: In a retrospective study conducted at the Endoscopy Unit of King Abdulaziz University Hospital, patients underwent stent placement, with or without palliative radiotherapy for inoperable esophageal cancer, during the period spanning January 2010 through December 2014. Ethical approval for this study was granted by the King Abdulaziz University Research Ethics Committee. Data were collected from the electronic database of the hospital. All patients underwent OGD before stenting to know site of tumor, length of tumor and degree of stricture. Barium meal and CT scan was also done in some cases to know exact characteristics of tumor. Stent was selected more than 2 cm longer than the length of tumor. Self expanding metallic stents were used in all cases. Confirmation of proper placement of stent was done using fluoroscopy. Complications post stenting were analysed. Results: A total of 15 cases were studied. Males were 53.3% while females were 46.7%. Youngest patient was 39 yr old and eldest was 79 years with mean 64.93 years. Mean height was 159.73 cm and mean weight 54.98 kilogram. Co-morbidities like DM was 20%, DM with HTN was 6.7%, bronchial asthma 13.3% and DM with HTN with IHD and Renal implant in 6.7%. Diagnosis at admission was esophageal squamous cell carcinoma in 33.3%, esophageal adeno-carcinoma in 53.3%, gastric cancer in 6.7%, tracho-esophageal fistula in 6.7%. Stage 3 was 13.3%, and stage 4 was 86.7%. Surgical resection and palliation was done in14.2%, and only palliation was done in 92.9% of cases. SEMS were used in all patients and majority had Niti-S stent placed in 73.3% and Wallflex in 13.3% and Ultraflex in 6.7% and Boston in 6.7% cases. Dysphagia was Indication of stenting in 100% of cases and stricture in 57.1% and stricture and recurrent aspiration in 42.9%. Post stenting complications were early in 20% and late in 40%. Tumor ingrowth was in 20%, GERD in 20%, Mild chest pain and discomfort in 10%, stent migration in 10%, fistula formation in 10%, chest pain and GERD in 10%, and aspiration and pneumonia in 20%. Conclusions: Self expanding metallic stents are invaluable in advanced oesophageal cancer for palliation and alleviation of symptoms and better quality of life. Patients prior to chemoradiotherapy may get benefit of stenting making oesophageal passage patent which may otherwise get occluded by edema caused by radiotherapy.

Clinical application of metallic stents in treatment of esophageal carcinoma

AIM: To evaluate the effects of self-expanding metal stents (SEMS) in patients with malignant esophageal obstruction and to analyze their prognosis and complications. METHODS: Seventy-four metallic stents were placed under fluoroscopic guidance in 66 patients with esophageal obstruction secondary to carcinoma, of whom, 6 cases were complicated by fistula. RESULTS: After seventy-two stents were successfully used in 66 cases without any severe complications (technical successful rate was 97%), the dysphagia score improved from 3.3±0.6 to 0.8±0.5 (P<0.01), and life quality improved significantly in all these patients. All fistulae were sealed immediately after coated stents were inserted in the six patients. New stents were placed in two patients: the stent migrated more than 2 cm, in one patients and the stent slipped into stomach in the other. Minor bleeding was found only in 28 patients during the operation. Reobstruction was found in 12 patients, but was successfully cured under endoscopy. The survival rate was 78%, 57% and 11% for 6 mo, 1 year and 2 years respectively. CONCLUSION: Placement of SEMS is a simple, safe, quick and efficient surgical method for treating esophageal carcinoma obstruction. It may be used mainly as a palliative treatment of esophageal obstruction secondary to carcinoma.

Endoscopic therapy using a self-expandable metallic stent with an anti-migration system for postorthotopic liver transplantation anastomotic biliary stricture

BACKGROUND Endoscopic therapy using multiple plastic stents(MPSs)is the standard therapy for postorthotopic liver transplantation(p-OLT)anastomotic biliary stricture(ABS).However,this approach demands repeated procedures.Recent studies us-ing fully covered self-expandable metallic stents(FCSEMS)have shown en-couraging results,but migration occurs in 10%to 40%of cases.The objective of this retrospective study was to evaluate the efficacy of endoscopic treatment using FCSEMS with an anti-migration system(Am-FCSEMS)in patients with p-OLT ABS.AIM To evaluate the efficacy of endoscopic treatment using an Am-FCSEMS in patients with p-OLT ABS.METHODS This study was conducted in a private tertiary care centre in S?o Paulo,Brazil and was approved by our institution's Human Research Committee.From April 2018 to October 2020,regardless of previous endoscopic treatment(MPS or FCSEMS),17 patients with p-OLT ABS and indications for endoscopic therapy were included in this study.The exclusion criteria were pregnancy,nonanastomotic biliary or hilar stricture,hepatic artery stenosis/thrombosis,isolated biliary fistulae,a distance shorter than 2 cm from the stricture to the hepatic hilum,and patient refusal.The primary endpoint was the efficacy of p-OLT ABS endoscopic treatment using an Am-FCSEMS that re-mained in place for a 12-mo period.Biliary sphincterotomy was performed in patients with native papilla,and an Am-FCSEMS(10 mm in final diameter and 60 or 80 mm in length)was placed(Hanarostent TM MI Tech,Co).Balloon stricture dilation was performed only if necessary to introduce the stent.RESULTS Three patients were excluded due to loss to follow-up before stent removal.Among the 14 patients included and followed,7 were women,and the average age was 56 years(range:28-76).The average period of Am-FCSEMS placement was 362±109 d.Technical success occurred in all 14 patients(100%).There were no cases of distal stent migration.Complete resolution of the stricture occurred in 13/14 patients(92.85%).Adverse events occurred in 3/14 patients(21.42%):2 patients with mild acute pancreatitis(14.28%)and 1 patient(7.14%)with stent dysfunction(occlusion by biliary sludge and stones,which was treated endoscopically without the need for stent removal).No deaths occurred related to therapy.All stents were removed using foreign body forceps or snares without difficulty.After Am-FCSEMS removal,all 13 patients who had ABS resolution were followed-up for an average of 411±172 d,and there was no stricture recurrence or need for further endoscopic therapy.CONCLUSION In this retrospective study,endoscopy therapy using an Am-FCSEMS for p-OLT ABS was safe and effective,with a high stricture re-solution rate that was probably due to the absence of stent migration.

Closure of a persistent sphincterotomy-related duodenal perforation by placement of a covered self-expandable metallic biliary stent

Retroperitoneal duodenal perforation as a result of endoscopic biliary sphincterotomy is a rare complication, but it is associated with a relatively high mortality risk, if left untreated. Recently, several endoscopic techniques have been described to close a variety of perforations. In this case report, we describe the closure of a persistent sphincterotomy-related duodenal perforation by using a covered self-expandable metallic biliary (CEMB) stent. A 61-year-old Greek woman underwent an endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy for suspected choledo-cholithiasis, and a retroperitoneal duodenal perforation (sphincterotomy-related) occurred. Despite initial conservative management, the patient underwent a laparotomy and drainage of the retroperitoneal space. After that, a high volume duodenal fistula developed. Six weeks after the initial ERCP, the patient underwent a repeat endoscopy and placement of a CEMB stent with an indwelling nasobiliary drain. The fistula healed completely and the stent was removed two weeks later. We suggest the transient use of CEMB stents for the closure of sphincterotomy-related duodenal perforations. They can be placed either during the initial ERCP or even later if there is radiographic or clinical evidence that the leakage persists.