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.

Clinical application of trans-sinus gastric stent placement and drainage in the management of persistent external pancreatic fistula after minimal access retroperitoneal pancreatic necrosectomy in severe acute pancreatitis patients

Background:Persistent external pancreatic fistula(EPF)in patients with pancreatic duct disruption or disconnection can result from minimal access to retroperitoneal pancreatic necrosectomy(MARPN)in severe acute pancreatitis patients,which is a difficult problem for clinicians and requires a long treatment duration.This study aimed to investigate the effectiveness and safety of trans-sinus gastric stent placement and drainage using interventional technology in the management of persistent EPF after MARPN in severe acute pancreatitis.Methods:From August 2018 to December 2020,the data of 9 patients with persistent EPF treated with trans-sinus gastric stent placement and drainage in our hospital were retrospectively collected.The main outcome measures were technical success rate,recurrence rate,new pancreatic fluid collection,morbidity,and mortality.All patients were followed up after the procedure through clinic visits and imaging modalities.Results:The median age of the patients was 46 years(30-61 years).The median persistent EPF duration was 5 months(2-12 months).The median follow-up time was 41 months(range,20-47 months).The median operation time was 48 minutes(range,40-54 minutes),and the technical success rate was 100%.Seven days after treatment,the percutaneous drainage tubes of all patients were removed.Six months after the procedure,2 patients lost the stents,and one of those patients suffered from a pseudocyst,which gradually increased to a maximum diameter of 7 cm over 9 months.Therefore,a double pigtail drainage tube was placed under the guidance of an endoscope.The second of these 2 patients had no recurrence or pseudocyst.Twelve months after the procedure,another 3 patients lost the stents;18 months after the procedure,another 2 patients lost the stents.These patients had no recurrence as well.No other adverse events or deaths occurred during the study period.Conclusion:Trans-sinus tract gastric stent placement and drainage are safe and effective in the treatment of persistent EPF after MARPN in severe acute pancreatitis patients.However,this study had a small sample size and did not include a comparative group.

Diagnosis and treatment for advanced hilar cholangiocarcinoma:experience of 24 cases

The aim of this paper is to evaluate the effi-cacy of the surgical treatment for advanced hilar cholan-giocarcinoma(CCA)in order to improve the resection rate and curative effect.A retrospective analysis was performed on the data of 24 patients who had under-gone surgical treatment for advanced hilar CCA.According to the Bismuth classification,there were four cases of type IIIa,six cases of type IIIb,and 14 cases of type IV.Based on the treatment approaches,these patients were divided into three groups:①Radical resection group:There were five cases(one type IIIa,three type IIIb,and one type IV).The tumor visible to the naked eyes was resected thoroughly and the cut mar-gin was free of tumor by microscopic examination.Then,Roux-en-Y hepatico-jejunal anastomosis was per-formed to restore the bile flow.②Palliative resection group:There were 11 cases.The bile flow was restored by Roux-en-Y hepatico-jejunal anastomosis directly in five cases(two type IIIa,three type IIIb)and by internal drainage through a hepatico-jejunal bridge in the other six cases(one type IIIa,five type IV).③Simple internal biliary drainage group:There were eight cases of type IV,including three cases with the internal drainage through hepatico-jejunal bridge by laparotomy,three cases with endoscopic retrograde biliary drainage(ERBD),two cases with percutaneous transhepatic biliary drainage(PTBD).The rate of radical resection was 20.8%and the overall resection rate was 66.7%.All of the 24 patients were fol-lowed-up.The cumulative surviving rates were significantly different among these three groups(Log-rank x2=17.56,P=0.0002).For advanced hilar CCA,the best choice of treatment is radical resection.If radical resection is impractical,palliative resection combined with partial hepatectomy can significantly prolong the survival time.Internal drainage through a hepatico-jejunal bridge can enhance the surgical resection rate and decrease the occur-rence rate of postoperative biliary leakage.