Safety and efficacy of Kaffes intraductal self-expanding metal stents in the management of post-liver transplant anastomotic strictures

BACKGROUND Endoscopic management is the first-line therapy for post-liver-transplant anas-tomotic strictures.Although the optimal duration of treatment with plastic stents has been reported to be 8-12 months,data on safety and duration for metal stents in this setting is scarce.Due to limited access to endoscopic retrograde cholan-giopancreatography(ERCP)during the coronavirus disease 2019 pandemic in our centre,there was a change in practice towards increased usage and length-of-stay of the Kaffes biliary intraductal self-expanding stent in patients with suitable anatomy.This was mainly due to the theoretical benefit of Kaffes stents allowing for longer indwelling periods compared to the traditional plastic stents.METHODS Adult liver transplant recipients aged 18 years and above who underwent ERCP were retrospectively identified during a 10-year period through a database query.Unplanned admissions post-Kaffes stent insertion were identified manually through electronic and scanned medical records.The main outcome was the incidence of complications when stents were left indwelling for 3 months vs 6 months.Stent efficacy was calculated via rates of stricture recurrence between patients that had stenting courses for≤120 d or>120 d.RESULTS During the study period,a total of 66 ERCPs with Kaffes insertion were performed in 54 patients throughout their stenting course.In 33 ERCPs,the stent was removed or exchanged on a 3-month interval.No pancreatitis,perfor-ations or deaths occurred.Minor post-ERCP complications were similar between the 3-month(abdominal pain and intraductal migration)and 6-month(abdominal pain,septic shower and embedded stent)groups-6.1%vs 9.1%respectively,P=0.40.All strictures resolved at the end of the stenting course,but the stenting course was variable from 3 to 22 months.The recurrence rate for stenting courses lasting for up to 120 d was 71.4%and 21.4%for stenting courses of 121 d or over(P=0.03).There were 28 patients that were treated with a single ERCP with Kaffes,21 with removal after 120 d and 7 within 120 d.There was a significant improvement in stricture recurrence when the Kaffes was removed after 120 d when a single ERCP was used for the entire stenting course(71.0%vs 10.0%,P=0.01).CONCLUSION Utilising a single Kaffes intraductal fully-covered metal stent for at least 4 months is safe and efficacious for the management of post-transplant anastomotic strictures.

Covered self expandable metallic stent with flared plastic one inside for pancreatic pseudocyst avoiding stent dislodgement

Endoscopic ultrasound-guided drainage has recently been recommended for increasing the drainage rate of endoscopically managed pancreatic fluid collections and decreasing the morbidity associated with conventional endoscopic trans-mural drainage. The type of stent used for endoscopic drainage is currently a major area of interest. A covered self expandable metallic stent (CSEMS) is an alternative to conventional drainage with plastic stents because it offers the option of providing a larger-diameter access fi stula for drainage, and may increase the fi nal success rate. One problem with CSEMS is dislodgement, so a metallic stent with flared or looped ends at both extremities may be the best option. An 85-year-old woman with severe comorbidity was treated with percutaneous approach for a large (20 cm) pancreatic pseudocyst with corpuscolated material inside. This approach failed. The patient was transferred to our institute for EUS-guided transmural drainage. EUS confi rmed a large, anechoic cyst with hyperechoic material inside. Because the cyst was large and contained mixed and corpusculated fluid, we used a metallic stent for drainage. To avoid migration of the stent and potential mucosal growth above the stent, a plastic prosthesis (7 cm, 10 Fr) with flaps at the tips was inserted inside the CSEMS. Two months later an esophagogastroduodenoscopy was done, and showed patency of the SEMS and plastic stents, which were then removed with a polypectomy snare. The patient experienced no further problems.

Self-expandable metallic stent placement plus laparoscopy for acute malignant colorectal obstruction

AIM:To investigate the clinical advantages of the stent-laparoscopy approach to treat colorectal cancer(CRC)patients with acute colorectal obstruction(ACO).METHODS:From April 2008 to April 2012,surgeryrelated parameters,complications,overall survival(OS),and disease-free survival(DFS)of 74 consecutive patients with left-sided CRC presented with ACO who underwent self-expandable metallic stent(SEMS)placement followed by one-stage open(n=58)or laparoscopic resection(n=16)were evaluated retrospectively.The stent-laparoscopy group was also compared with a control group of 96 CRC patients who underwent regular laparoscopy without ACO between January 2010 and December 2011 to explore whether SEMS placement influenced the laparoscopic procedure or reduced long-term survival by influencing CRC oncological characteristics.RESULTS:The characteristics of patients among these groups were comparable.The rate of conversion to open surgery was 12.5%in the stent-laparoscopy group.Bowel function recovery and postoperative hospital stay were significantly shorter(3.3±0.9 d vs 4.2±1.5 d and 6.7±1.1 d vs 9.5±6.7 d,P=0.016 and P=0.005),and surgical time was significantly longer(152.1±44.4 min vs 127.4±38.4 min,P=0.045)in the stent-laparoscopy group than in the stent-open group.Surgery-related complications and the rate of admission to the intensive care unit were lower in the stent-laparoscopy group.There were no significant differences in the interval between stenting and surgery,intraoperative blood loss,OS,and DFS between the two stent groups.Compared with those in the stentlaparoscopy group,all surgery-related parameters,complications,OS,and DFS in the control group were comparable.CONCLUSION:The stent-laparoscopy approach is a feasible,rapid,and minimally invasive option for patients with ACO caused by left-sided CRC and can achieve a favorable long-term prognosis.

Management of post-gastrectomy anastomosis site obstruction with a self-expandable metallic stent

Post-gastrectomy anastomosis site obstruction is a relatively rare complication after a subtotal gastrectomy.We present a case of a 75-year-old man who underwent a truncal vagotomy, omental patch, gastrojejunostomy, and Braun anastomosis for duodenal ulcer perforation and a gastric outlet obstruction.Following the 10 th postoperative day, the patient complained of abdominal discomfort and vomiting.We diagnosed post-gastrectomy anastomosis site obstruction by an upper gastrointestinal series and an upper endoscopic examination.We inserted a self-expandable metallic stent(SEMS) at the anastomosis site.The stent was fully expanded after deployment.On the day following the stent insertion, the patient began to eat, and his abdominal discomfort was resolved.This paper describes the successful management of post-gastrectomy anastomosis site obstruction with temporary placement of a SEMS.

Case of arterial hemorrhage after endoscopic papillary large balloon dilation for choledocholithiases using a covered self-expandable metallic stent

A 78-year-old male was admitted to our hospital because of choledocholithiasis.ERC demonstrated choledocholithiases with a maximum diameter of 13 mm, and we performed endoscopic papillary large balloon dilation(EPLBD) with a size of 15 mm.Immediately following the balloon deflation, spurting hemorrhage occurred from the orifice of the duodenal papilla.Although we performed endoscopic hemostasis by compressing the bleeding point with the large balloon catheter, we could not achieve hemostasis.Therefore, we placed a 10 mm fully covered selfexpandable metallic stent(SEMS) across the duodenal papilla, and the hemorrhage stopped immediately.After 1 wk of SEMS placement, duodenal endoscopy revealed ulcerative lesions in both the orifice of the duodenal papilla and the lower bile duct.A direct peroral cholangioscopy using an ultra-slim upper endoscope revealed a visible vessel with a longitudinal mucosal tear in the ulceration of the lower bile duct.We believe that the mucosal tear and subsequent ruptured vessel were caused by the EPLBD procedure.

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.

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.

A temporary self-expanding metallic stent for malignant colorectal obstruction

AIM:To investigate the clinical safety and efficacy of a temporary self-expanding metallic stent(SEMS) for malignant colorectal obstruction.METHODS:From September 2007 to June 2012,33 patients with malignant colorectal obstruction were treated with a temporary SEMS.The stent had a tubular configuration with a retrieval lasso attached inside the proximal end of the stent to facilitate its removal.The SEMS was removed one week after placement.Clinical examination,abdominal X-ray and a contrast study were prospectively performed and both initial and follow-up data before and at 1 d,1 wk,and 1 mo,3 mo,6 mo and 12 mo after stent placement were obtained.Data collected on the technical and clinical success of the procedures,complications,need for reinsertion and survival were analyzed.RESULTS:Stent placement and removal were technically successful in all patients with no procedurerelated complications.Post-procedural complications included stent migration(n = 2) and anal pain(n = 2).Clinical success was achieved in 31(93.9%) of 33 patients with resolution of bowel obstruction within 3 d of stent removal.Eleven of the 33 patients died 73.81 ± 23.66 d(range 42-121 d) after removal of the stent without colonic re-obstruction.Clinical success was achieved in another 8 patients without symptoms of obstruction during the follow-up period.Reinsertion of the stent was performed in the remaining 12 patients with re-obstruction after 84.33 ± 51.80 d of follow-up.The mean and median periods of relief of obstructive symptoms were 97.25 ± 9.56 d and 105 ± 17.43 d,respectively,using Kaplan-Meier analysis.CONCLUSION:Temporary SEMS is a safe and effective approach in patients with malignant colorectal obstruction due to low complication rates and good medium-term outcomes.

Self-expandable metal stents in patients with postoperative delayed gastric emptying after distal gastrectomy

AIM To investigate the efficacy and safety of endoscopic stent insertion in patients with delayed gastric emptying after gastrectomy.METHODS In this study, we prospectively collected data from patients who underwent stent placement for delayed gastric emptying(DGE) after distal gastrectomy between June 2010 and April 2017, at a tertiary referral academic center. Clinical improvement, complications, and consequences after stent insertion were analyzed.RESULTS Technical success was achieved in all patients(100%). Early symptom improvement was observed in 15 of 20 patients(75%) and clinical success was achieved in all patients. Mean follow-up period was 1178.3 ± 844.1 d and median stent maintenance period was 51 d(range 6-2114 d). During the follow-up period, inserted stents were passed spontaneously per rectum without any complications in 14 of 20 patients(70%). Symptom improvement was maintained after stent placement without the requirement of any additional intervention in 19 of 20 patients(95%).CONCLUSION Endoscopic stent placement provides prompt relief of obstructive symptoms. Thus, it can be considered an effective and safe salvage technique for post-operative DGE.

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.

Chronic pancreatic pain successfully treated by endoscopic ultrasound-guided pancreaticogastrostomy using fully covered self-expandable metallic stent

One of the most common symptoms presenting in patients with chronic pancreatitis is pancreatic-type pain.Obstruction of the main pancreatic duct in chronic pancreatitis can be treated by a multitude of therapeutic approaches,ranging from pharmacologic,endoscopic and radiologic treatments to surgical interventions.When the conservative treatment approaches fail to resolve symptomatic cases,however,endoscopic retrograde pancreatography with pancreatic duct drainage is the preferred second approach,despite its well-recognized drawbacks.When the conventional transpapillary approach fails to achieve the necessary drainage,the patients may benefit from application of the less invasive endoscopic ultrasound(EUS)-guided pancreatic duct interventions.Here,we describe the case of a 42-year-old man who presented with severe abdominal pain that had lasted for 3 mo.Computed tomography scanning showed evidence of chronic obstructive pancreatitis with pancreatic duct stricture at genu.After conventional endoscopic retrograde pancreaticography failed to eliminate the symptoms,EUS-guided pancreaticogastrostomy(PGS)was applied using a fully covered,self-expandable,10-mm diameter metallic stent.The treatment resolved the case and the patient experienced no adverse events.EUS-guided PGS with a regular biliary fully covered,self-expandable metallic stent effectively and safely treated pancreatictype pain in chronic pancreatitis.

Placement of a fully covered self-expandable metal stent in a young patient with chronic pancreatitis

Plastic stent insertion is a treatment option for pancreatic duct stricture with chronic pancreatitis.However, recurrent stricture is a limitation after removing the plastic stent.Self-expandable metal stents have long diameters and patency.A metal stent has become an established management option for pancreatic duct stricture caused by malignancy but its use in benign stricture is still controversial.We introduce a young patient who had chronic pancreatitis and underwent several plastic stent insertions due to recurrent pancreatic duct stricture.His symptoms improved after using a fully covered self-expandable metal covered stent and there was no recurrence found at follow-up at the outpatient department.

Development of a biliary multi-hole self-expandable metallic stent for bile tract diseases: A case report

BACKGROUND Uncovered stents used for malignant obstructions in the biliary tree, especially in the hilar area, are prone to obstruction by tumor ingrowths. In comparison, however, covered stents may block bile duct branches and are at risk of migration. We have developed a multi-hole self-expandable metallic stent (MHSEMS), with a hole in each cell, to prevent the obstruction of bile duct branches. In addition, the holes may prevent migration due to small ingrowths by reducing the tension of the membrane. CASE SUMMARY MHSEMS were placed in five patients with a malignant obstruction and one with post-endoscopic sphincterotomy bleeding. Each MHSEMS was successfully deployed in all cases. Patients showed no complications. Two cases were reviewed. Case 1: A 74-year-old male presented with jaundice and was diagnosed with a sigmoid colon cancer and giant liver metastases in the right liver lobe. A MHSEMS was placed in the left bile duct. The jaundice improved and peroral cholangioscopy was performed. Case 2: A 90-year-old female was admitted to hospital for jaundice and diagnosed with cholangiocarcinoma. A MHSEMS was placed in the left bile duct but after 8 months the stent became obstructed by tumor ingrowth. We treated the patient by ablation therapy. A silicone cover separated the internal bile duct from the surrounding tissue, protecting the latter from thermal injury during treatment by endobiliary ablation of the reobstruction. CONCLUSION A MHSEMS is a new choice of stent for biliary tract diseases.

Endoscopic transpapillary gallbladder drainage with replacement of a covered self-expandable metal stent

Endoscopic self-expandable metal stent (SEMS) placement has become a standard palliative therapy for pa- tients with malignant biliary obstruction. Acute cholecystitis after SEMS placement is a serious complication. We report a patient with an acute cholecystitis after covered SEMS placement, who was managed successfully with endoscopic transpapillary gallbladder drainage (ETGBD) and replacement of the covered SEMS. An 85-year-old man with pancreatic cancer suffered from acute cholecystitis after covered SEMS placement. It was impossible to perform percutaneous transhepatic gallbladder drainage. After removal of the covered SEMS with a snare, a 7Fr double pigtail stent was placed between the gallbladder and duodenum, subsequently followed by another covered SEMS insertion into the common bile duct beside the gallbladder stent. The cholecystitis improved immediately after ETGBD. ETGBD with replacement of the covered SEMS thus proved to be effective for treatment of patients with acute cholecystitis after covered SEMS placement.

Complications of airway self-expandable metallic stent in benign airway diseases

Objectives: To present the complications of Ultraflex Self-Expandable Metallic Stents (SEMSs) applied in patients with benign tracheobronchial diseases. Methods: Eighty patients received 124 SEMSs were retrospectively reviewed in a tertiary hospital. Results: The baseline characteristics of patients received SEMS implantation including age (mean + standard deviation: 62.5 + 14.8 years), gender (male, 60.5%), smoking (46.8%), forced expiratory volume in first one second (FEV1) (mean + standard deviation, 0.92 +0.41 L/s), follow-up days after SEMS implantation (median (interquartile range);457 (131 - 897)) and covered SEMS (33.9%) were listed. Symptoms improved after SEMS implantation among 95 patients (76.6%). Time to complications developed was 236 (median;interquartile range, 59 - 672) days. The overall complication rate was 41.9% after SEMS implantation. The complications included SEMS migration (6.5%), granuloma (19.3%) and SEMS fracture (16.1%). Successful management rates of SEMS migration, granuloma and SEMS fracture were up to 100%, 83.3%, and 85% respectively. Conclusions: Patients received SEMS implantation due to benign conditions had poor lung function and were old. The complication rate in patients with benign conditions was high after longer follow-up period, however, successful management achieved in most patients with complications.

Endoscopic removal of a self-expanding metallic airway stent: A case report

Self-expanding metallic stents are sometimes placed for the management of obstructing airway lesions or conditions such as airway wall malacia or tracheal stenosis. However, endoscopic removal of these devices from the airway can pose extreme challenges for both clinical airway management as well as for the administration of general anesthesia. We report on a 61-yearold man with a complex cardiac history presenting for endoscopic stent removal necessitated by the formation of extensive granulation tissue. Comorbidities included a history of myocardial infarction, an ischemic cardiomyopathy with severe left heart failure(ejection fraction of 25%), mild right heart failure, 2+ tricuspid regurgitation status post tricuspid valve repair, and atrial fibrillation. An automatic external(wearable) cardiac defibrillator(Zoll Life Vest) was also in place. Induction of anesthesia was carried out using etomidate, with maintenance of anesthesia carried out with a propofol infusion(total intravenous anesthesia). Rocuronium was used for neuromuscular blockade. A size 4 i Gel supraglottic airway and, later, rigid bronchoscopy formed the basis for airway management. Stable conditions were met through the 2-h procedure, and the patient recovered uneventfully. Our successful experience in this case leads us to propose further use of a supraglottic airway in conjunction with total intravenous anesthesia for these procedures.

Treatment of gastric outlet and duodenal obstructions with uncovered expandable metal stents

AIM:To investigate and evaluate the technical feasibility and clinical effectiveness of fluoroscopically guided peroral uncovered expandable metal stent placement to treat gastric outlet and duodenal obstructions. METHODS:Fifteen consecutive patients underwent peroral placement of Wallstent^(TM)Enteral Endoprosthesis to treat gastric outlet and duodenal obstructions(14 malignant,1 benign).All procedures were completed under fluoroscopic guidance without endoscopic assistance.Follow-up was completed until the patients died or were lost,and the clinical outcomes were analyzed. RESULTS:The technique success rate was 100%,and the oral intake was maintained in 12 of 14 patients varying from 7 d to 270 d.Two patients remained unable to resume oral intake,although their stents were proven to be patent with the barium study.One patient with acute necrotizing pancreatitis underwent enteral stenting to treat intestinal obstruction,and nausea and vomiting disappeared.Ten patients died during the follow- up period,and their mean oral intake time was 50 d. No procedure-related complications occurred.Stent migration to the gastric antrum occurred in one patient 1 year after the procedure,a tumor grew at the proximal end of the stent in another patient 38 d post-stent insertion. CONCLUSION:Fluoroscopically guided peroral metal stent implantation is a safe and effective method to treat malignant gastrointestinal obstructions,and complications can be ignored based on our short-term study.Indications for this procedure should be discreetly considered because a few patients may not benefit from gastrointestinal insertion,but some benign gastrointestinal obstructions can be treated using this procedure.

Efficacy and safety of standard and anti-reflux self-expanding metal stent: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND Self-expanding metal stents are the main palliative treatment modality for unresectable esophageal cancer. Gastroesophageal reflux is a common adverse outcome after placement of esophageal stent for cancer involving the gastroesophageal junction and the gastric cardia. Anti-reflux stents with valve have been designed to prevent the acid reflux. The superiority of anti-reflux stent over standard stent in preventing gastroesophageal reflux has not been established well. This study compares the anti-reflux stent and the standard stent in terms of their efficacy to prevent acid reflux.AIM To compare the standard and the anti-reflux stents in terms of their efficacy,safety, and complications.METHODS The meta-analysis included 8 randomized clinical trials(RCTs) to compare pooled outcomes of total 395 patients. Primary outcomes include improvement in reflux symptoms and dysphagia score. Secondary outcomes include complications of stent migration, occlusion, and bleeding.RESULTS A total of eight RCTs were included in the meta-analysis. Compared to the standard stent, the anti-reflux stent showed a trend towards reduction in the dysphagia score without reaching a statistical significance [Standardized mean difference(SMD):-0.33(-0.71, 0.05); P = 0.09, I2: 37%]. There was no statistical difference in the gastrointestinal reflux(GER) scores between the two types of stents [SMD:-0.17(-0.78, 0.45); P = 0.008, I2: 74%]. Compared to standard stent,anti-reflux stent showed no difference in the risk of stent migration [OR: 1.37(0.66, 2.83); P = 0.40, I2: 0 %], bleeding [OR: 1.43(0.40, 5.13); P = 0.59, I2: 0 %], and obstruction [OR: 1.66(0.60, 4.60); P = 0.33, I2: 0 %].CONCLUSION Traditional self-expanding standard esophageal stent and anti-reflux stent with valve are similar in terms of outcomes and complications.

Role of self expandable stents in management of colorectal cancers

Acute malignant colorectal obstruction is a complication of colorectal cancer that can occur in 7%-29% of patients. Self-expanding metallic stent placement for malignant colorectal obstruction has gained popularity as a safe and effective procedure for relieving obstruction. This technique can be used in the palliation of malignant colorectal obstruction, as a bridge to elective surgery for resectable colorectal cancers, palliation of extracolonic malignant obstruction, and for nonmalignant etiologies such as anastomotic strictures, Crohn's disease, radiation therapy, and diverticular diseases. Self-expanding metallic stent has its own advantages and disadvantages over the surgery in these indications. During the insertion of the self-expanding metallic stent, and in the followup, short term and long term morbidities should be kept in mind. The most important complications of the stents are perforation, stent obstruction, stent migration, and bleeding. Additionally, given the high risk of perforation, if a patient is treated or being considered fortreatmentwith antiangiogenic agents such as bevacizumab, it is not recommended to use self-expanding metallic stent as a palliative treatment for obstruction. Therefore, there is a need for careful clinical evaluation for each patient who is a candidate for this procedure. The purpose of this review was to evaluate self-expanding metallic stent in the management of the obstruction of the colon due to the colorectal and extracolonic obstruction.

Endoscopic transluminal pancreatic necrosectomy using a self-expanding metal stent and high-flow water-jet system

Walled-off pancreatic necrosis and a pancreatic abscess are the most severe complications of acute pancreatitis. Surgery in such critically ill patients is often associated with significant morbidity and mortality within the first few weeks after the onset of symptoms. Minimal invasive approaches with high success and low mortality rates are therefore of considerable interest. Endoscopic therapy has the potential to offer safe and effective alternative treatment. We report here on 3 consecutive patients with infected walled-off pancreatic necrosis and 1 patient with a pancreatic abscess who underwent direct endoscopic necrosectomy 19-21 d after the onset of acute pancreatitis. The infected pancreatic necrosis or abscess was punctured transluminally with a cystostome and, after balloon dilatation, a non-covered self-expanding biliary metal stent was placed into the necrotic cavity. Following stent deployment, a nasobiliary pigtail catheter was placed into the cavity to ensure continuous irrigation. After 5-7 d, the metal stent was removed endoscopically and the necrotic cavity was entered with a therapeutic gastroscope. Endoscopic debridement was performed via the simultaneous application of a high-flow water-jet system; using a flush knife, a Dormia basket, and hot biopsy forceps. The transluminal endotherapy was repeated 2-5 times daily during the next 10 d. Supportive care included parenteral antibiotics and jejunal feeding. All patients improved dramatically and with resolution of their septic conditions; 3 patients were completely cured without any further complications or the need for surgery. One patient died from a complication of prolonged ventilation severe bilateral pneumonia, not related to the endoscopic procedure. No procedure related complications were observed. Transluminal endoscopic necrosectomy with temporary application of a self-expanding metal stent and a high-flow water-jet system shows promise for enhancing the potential of this endoscopic approach in patients with walled-off pancreatic necrosis and/or a pancreatic abscess.