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.

Fully covered metal biliary stents: A review of the literature

Fully covered self-expandable metal stents(FCSEMS)represent the latest advancement of metal biliary stents used to endoscopically treat a variety of obstructive biliary pathology.A large stent diameter and synthetic covering over the tubular mesh prolong stent patency and reduce risk for tissue hyperplasia and tumor ingrowth.Additionally,FCSEMS can be easily removed.All these features address issues faced by plastic and uncovered metal stents.The purpose of this paper is to comprehensively review the application of FCSEMS in benign and malignant biliary strictures,biliary leak,and post-sphincterotomy bleeding.

Contrast-free air cholangiography-assisted unilateral plastic stenting in malignant hilar biliary obstruction

BACKGROUND:Endoscopic palliation in malignant hilar biliary obstruction requires endoscopic retrograde cholangiopancreatography (ERCP),whereas contrast injection leads to cholangitis.Contrast-free metal stenting with or without magnetic resonance cholangiopancreatography (MRCP) has shown encouraging results,but MRCP and metal stents are costly.There have been no reports on the use of air cholangiography.METHODS:We prospectively evaluated the role of air cholangiography-assisted unilateral plastic stenting in 10 patients with type Ⅱ malignant hilar biliary obstruction.A retrospectively analysed group of 10 patients treated with contrast-free unilateral metal stenting served as historical controls.RESULTS:Ten patients with unresectable type Ⅱ malignant hilar biliary obstruction were studied.Air cholangiography detected type Ⅱ obstruction in all patients,similar to MRCP.The patients underwent unilateral stenting.Successful endoscopic drainage was achieved in all patients.The mean patency of the stent was 95.8±17.5 days in the study group and 143.9±115.1 days in the control group (P=0.20).The mean survival was 121.8±41.6 days in the study group and 154.9±122.5 days in the control group (P=0.42).KaplanMeier analysis showed an estimated median survival of 100:95% CI (65.9,134.1) days in the study group and 98:95% CI (84.1,111.9) days in the control group (P=0.62).Cholangitis occurred in none of the patients and there were no 30-day deaths nor major complications.Air cholangiographyassisted unilateral plastic stenting was cheaper than contrastfree unilateral metal stenting.CONCLUSION:Air cholangiography-assisted unilateral plastic stenting is as safe and effective as contrast-free unilateral metal stenting in type Ⅱ malignant hilar biliary obstruction for palliating patients,but it is cheaper.

Late-onset severe biliary bleeding after endoscopic pigtail plastic stent insertion

Here, we report our experience with a case of severe biliary bleeding due to a hepatic arterial pseudoaneurysm that had developed 1 year after endoscopic biliary plastic stent insertion. The patient, a 78-year-old woman, presented with hematemesis and obstructive jaundice. Ruptured hepatic arterial pseudoaneurysm was diagnosed, which was suspected to have been caused by long-term placement of an endoscopic retrograde biliary drainage(ERBD) stent. This episode of biliary bleeding was successfully treated by transarterial embolization(TAE). Pseudoaneurysm leading to hemobilia is a rare but potentially fatal complication in patients with long-term placement of ERBD. TAE is a minimally invasive procedure that offers effective treatment for biliary bleeding.

New anti-reflux plastic stent to reduce the risk of stent-related cholangitis in the treatment of biliary strictures

BACKGROUND There is little data available on the role of new anti-reflux plastic stents(ARPSs).AIM To compare the use of ARPSs with that of traditional plastic stents(TPSs)for patients with biliary strictures.METHODS Consecutive patients with biliary strictures who underwent first endoscopic biliary stenting between February 2016 and May 2019 were included.The onset of stent-related cholangitis,stent patency,clinical success,and other adverse events were evaluated.RESULTS Sixty-seven patients in the ARPS group and 66 patients in the TPS group were included in the final analyses.Fewer patients experienced stent-related cholangitis in the ARPS group than that in the TPS group(8 patients vs 18 patients;P=0.030).The median time till the onset of first stent-related cholangitis was later in the ARPS group than that in the TPS group(128.5 d vs 76 d;P=0.039).The cumulative median stent patency in the ARPS group was 185 d,which was significantly longer than that in the TPS group(133 d;P=0.001).The clinical success rates and other adverse events did not significantly differ between both groups.CONCLUSION Placement of new ARPS might be a safe and effective optional therapeutic strategy to reduce the risk of stent-related cholangitis and prolong stent patency.

Multicenter study of endoscopic preoperative biliary drainage for malignant distal biliary obstruction

AIM: To determine the optimal method of endoscopic preoperative biliary drainage for malignant distal biliary obstruction.METHODS: Multicenter retrospective study was conducted in patients who underwent plastic stent (PS) or nasobiliary catheter (NBC) placement for resectable malignant distal biliary obstruction followed by surgery between January 2010 and March 2012. Procedure-related adverse events, stent/catheter dysfunction (occlusion or migration of PS/NBC, development of cholangitis, or other conditions that required repeat endoscopic biliary intervention), and jaundice resolution (bilirubin level < 3.0 mg/dL) were evaluated. Cumulative incidence of jaundice resolution and dysfunction of PS/NBC were estimated using competing risk analysis. Patient characteristics and preoperative biliary drainage were also evaluated for association with the time to jaundice resolution and PS/NBC dysfunction using competing risk regression analysis.RESULTS: In total, 419 patients were included in the study (PS, 253 and NBC, 166). Primary cancers included pancreatic cancer in 194 patients (46%), bile duct cancer in 172 (41%), gallbladder cancer in three (1%), and ampullary cancer in 50 (12%). The median serum total bilirubin was 7.8 mg/dL and 324 patients (77%) had ≥ 3.0 mg/dL. During the median time to surgery of 29 d [interquartile range (IQR), 30-39 d]. PS/NBC dysfunction rate was 35% for PS and 18% for NBC [Subdistribution hazard ratio (SHR) = 4.76; 95%CI: 2.44-10.0, P < 0.001]; the pig-tailed tip was a risk factor for PS dysfunction. Jaundice resolution was achieved in 85% of patients and did not depend on the drainage method (PS or NBC).CONCLUSION: PS has insufficient patency for preoperative biliary drainage. Given the drawbacks of external drainage via NBC, an alternative method of internal drainage should be explored.

Management of liver transplantation biliary stricture: Results from a tertiary hospital

AIM: To review results of endoscopic treatment for anastomotic biliary strictures after orthotopic liver transplantation(OLT) during an 8-year period. METHODS: This is a retrospective review of all endoscopic retrograde cholangiopancreatographys(ERCPs) performed between May 2006 and June 2014 in deceased OLT recipients with anastomotic stricture at a tertiary care hospital. Patients were divided into 2 groups, according to the type of stent used(multiple plastic or covered self-expandable metal stents), which was chose on a case-by-case basis and their characteristics. The primary outcome was anastomotic stricture resolution rate determined if there was no more than a minimum waist at cholangiography and a 10 mm balloon could easily pass through the anastomosis with no need for further intervention after final stent removal. Secondary outcomes were technical successrate, number or ERCPs required per patient, number of stents placed, stent indwelling, stricture recurrence rate and therapy for recurrent anastomotic biliary stricture(AS). Stricture recurrence was defined as clinical laboratorial and/or imaging evidence of obstruction at the anastomosis level, after it was considered completely treated, requiring subsequent interventional procedure.RESULTS: A total of 195 post-OLT patients were assessed for eligibility. One hundred and sixty-four(164) patients were diagnosed with anastomotic biliary stricture. ERCP was successfully performed in 157/164(95.7%) patients with AS, that were treated with either multiple plastic(n = 109) or metallic billiary stents(n = 48). Mean treatment duration, number of procedures and stents required were lower in the metal stent group. Acute pancreatitis was the most common procedure related complication, occurring in 17.1% in the covered self-expandable metal stents(c SEMS) and 4.1% in the multiple plastic stent(MPS) group. Migration was the most frequent stent related complication, observed in 4.3% and 5.5%(c SEMS and MPS respectively). Stricture resolution was achieved in 86.8% in the c SEMS group and in 91% in MPS group. Stricture recurrence after a median follow up of 20 mo was observed in 10(30.3%) patients in the c SEMS and 7(7.7%) in the plastic stent group, a statistically significant difference(P = 0.0017). Successful stricture resolution after secondary treatment was achieved in 66.6% and 62.5% of patients respectively in the c SEMS and plastic stents groups. CONCLUSION: Multiple plastic stents are currently the first treatment option for AS in patients with duct-toduct anastomosis. c SEMS was associated with increased pancreatitis risk and higher recurrence rate.

Endoscopic pancreatic duct and biliary duct stenting in treatment of chronic pancreatitis with distal benign biliary stricture: a single-center experience

BACKGROUND: The development of endoscopic techniques such as endoscopic retrograde cholangiopancreatography (ERCP), endoscopic sphincterotomy (EST) and stenting are relatively new alternatives to surgery for the treatment of benign lesions in the biliary duct and pancreas. The objective of this study was to assess the value of stenting in the endoscopic pancreatic duct and biliary duct in the treatment of chronic pancreatitis with distal benign biliary stricture. METHODS: Twenty-two patients diagnosed with chronic pancreatitis with distal benign biliary stricture underwent endoscopic treatment in our center, with ERCP, EST, endoscopic retrograde biliary drainage (ERBD) and endoscopic retrograde pancreatic drainage (ERPD) with stents. A numeric rating scale was used to assess pain intensity. The clinical data on endoscopic therapies and recovery of the patients were recorded and compared. RESULTS: ERCPs were successfully performed in 21 patients and 1 (4.5%) failed because of pancreatic ductal variation. A total of 68 ERCPs were performed with 47 pancreatic duct stents and 39 biliary duct stents. The rate of complications was 13.2% (9/68). The abdominal pain score after endoscopic treatment was significantly reduced. The levels of bilirubin and alanine transaminase in all 21 patients were improved compared to those before endoscopic treatment.CONCLUSION: Endoscopic stent drainage of the pancreatic duct and biliary duct for chronic pancreatitis with distal biliary benign stricture can be selected as a safe, effective and minimally invasive therapeutic method.

Rare common bile duct metastasis of breast cancer:A case report and literature review

BACKGROUND Breast cancer is the most common tumor in women,and about one-third of cases develop metastatic disease.However,metastatic breast cancer rarely invades the common bile duct(CBD)directly without involving the liver,and involvement of the gastrointestinal tract is rare.Cases of such metastases pose a particular diagnostic challenge.CASE SUMMARY A 55-year-old female presented to the Department of Gastroenterology with complaint of a 2 mo history of right upper abdominal pain accompanied by pain in the right back,aggravated after eating greasy diet.The patient had received a diagnosis of breast cancer 3 years prior.Physical examination showed obvious superficial protuberant erythema on the left neck and chest skin,with slight tenderness and burning sensation.Endoscopic retrograde cholangiopancreatography showed an obstruction at the end of the CBD.Histopathology of the CBD and symptomatic skin biopsies showed positivity for cytokeratin 7 and trans-acting T-cell-specific transcription factor breast cancer biomarkers.A cancer embolus was also found in the skin vasculature.Accordingly,the diagnosis of breast cancer metastases to the skin and biliary ducts was made.A plastic biliary sent was placed,which relieved the right upper abdominal pain and protected against unnecessary hepatectomy surgery.CONCLUSION Although rare,biliary metastasis should be considered in patients with bile duct stenosis and a history of breast cancer.

ENDOSCOPIC STENT FOR PALLIATING MALIGNANT AND BENIGN BILIARY OBSTRUCTION

To study the techniques of placement of memory alloy plating gold biliary stent and plastic stent for palliation of malignant and benign biliary obstruction, and to assess its clinical effectiveness. Methods: The patients in plastic stent group included paplilla of duodenum inflamational strictures (n=24), common bile duct inflammational inferior segment strictures (n=4), choledocholithiasis (n=5), bile leak (n=11), bile duct surgery injurey (n=7) and pancreatic carcinoma (n=1). The patients in plating gold stent group included common bile duct carcinoma (n=5) and pancreatic carcinoma (n=6). Under fluoroscopic guidance the stent was inserted into biliary obstruction sites from oral cavity in all cases. Complications, liver function and blood serum amylase were investigated during the study period. Results: Successful stent placement was achieved in all cases. After operation of 7 days, in gold biliary stent groups, the rates of decrease of blood serum total bilirubin, glutamic-pyruvic transaminase, r-glutamyl transpeptidase and alkaline phosphatase were 67.16%, 58.37%, 40.63% and 41.54% respectively. In plastic stent group, the rates of decrease of STB, ALT, r-GT and AKP were 53.24%, 55.03%, 37.15%, 34.12% respectively. Early complication included post-ERCP pancreatitis and cholangititis. Occlusion of stent was the major late complication. Conclusion: Memory alloy plating gold biliary stent and plastic stent were safe and efficacious methods for malignant and benign biliary obstruction, and could improve patient抯 living quality. Plastic stent was an efficient complement for therapy of bile leak and bile duct injury.

Metallic ureteral stent in restoring kidney function: Nine case reports

BACKGROUND Retroperitoneal fibrosis is an exceptionally rare disease characterized by proliferation of fibrous tissue and inflammation in the retroperitoneum.It features many symptoms in the kidneys and in other organs and usually leads to ureteral obstruction.CASE SUMMARY Here we present 9 consecutive cases of idiopathic retroperitoneal fibrosis(IRPF)in patients who presented to the Department of Nephrology or Department of Rheumatology,Xuanwu Hospital,Capital Medical University,Beijing,China,between January 2012 and June 2017 with ureteral obstruction due to external compression of the ureter that led to hydronephrosis and kidney dysfunction.Computed tomography imaging was used to identify hydronephrosis and ureteral obstruction and to evaluate kidney function.Each patient was diagnosed with IRPF based on clinical observation and computed tomography examination results.To restore kidney function,a retrograde metallic stent was placed in the ureter under X-ray guidance 2 d after each patient’s admission.No perioperative complications occurred in any patient,but postoperative complications occurred in two patients as follows:Patient 2 had stent migration and repeated metallic stent infections that resolved with treatment;and patient 4 had postoperative hematuria because he resumed normal activities too soon after stent placement(contrary to instruction).Placement of the metallic ureteral stents provided relief from ureteral obstruction and restored kidney function in all patients.CONCLUSION Our 9-case series underscores the utility and efficacy of applying the Resonance®metallic ureteral stent to treat ureteral obstruction in patients with IRPF.For all retroperitoneal fibrosis cases in our series,ureteral stents provided effective relief and were shown to reduce the incidence rate of perioperative and postoperative complications.