Successful outcome of sphincterotomy and 7 French pigtail stent insertion in the management of post-cholecystectomy bile leaks

BACKGROUND:Endoscopic retrograde cholangiopancrea-tography(ERCP)is widely used to manage post-cholecystectomy bile leaks.However,the best endoscopic intervention remains controversial.We investigated the success of a 7 French double pigtail stent following sphincterotomy in the management of such bile leaks. METHODS:Between July 1998 and June 2008,48 patients were referred for ERCP for presumed post-cholecystectomy bile leaks.Leaks were confirmed at ERCP and managed by a combination of sphincterotomy and stent insertion unless contraindicated. RESULTS:Bile duct cannulation was successful in 44(91.7%)patients.A leak of the cystic duct was demonstrated in 19(43.2%)patients,the duct of Luschka in 11(25.0%),and the common hepatic duct in 5 (11.4%).Complete transection of the common bile duct occurred in 4 patients.The remaining patients had no cholangiographic evidence of a leak.Sphincterotomy was performed in 34 patients.A 7 French double pigtail plastic stent was placed in all 35 patients with cholangiographic evidence of a bile leak.No bile leaks were demonstrated at a follow-up of 8-16 weeks and all stents were removed successfully. CONCLUSION:The combination of sphincterotomy and insertion of a 7 French double pigtail stent results in excellent outcomes in the management of post-cholecystectomy bile leaks.

Endoscopic bilateral stent-in-stent placement for malignant hilar obstruction using a large cell type stent

BACKGROUND： Bilateral stent-in-stent （SIS） self-expandable metal stent placement is technically chghallenging for palliation of unresectable malignant hilar obstruction. In the SIS technique, the uniform large cell type biliary stent facilitates contralateral stent deployment through the mesh of the first metallic stent. This study aimed to assess the technical success and clinical effectiveness of this technique with a uniform large cell type biliary stent. METHODS： Thirty-one patients who underwentlbilateral SIS placement using a large cell type stent were reviewed retrospectively. All patients showed malignant hilarl obstruction （Bismuth types Ⅱ, Ⅲ, Ⅳ） with different etiologies. RESULTS： Sixteen （51.6%） patients were male. The mean age of the patients was 67.0±14.0 years. Most patients were diagnosed as having hilar cholangiocarcinoma （58.1%） and gallbladder cancer （29.0%）. Technical success rate was 83.9%. Success was achieved more frequently in patients without masses obstructing the biliary confluence （MOC） than those with MOC （95.2% vs 60.0%, P=0.03）. Functional success rate was 77.4%. Complications occurred in 29.0% of the patients. These tended to occur more frequently in patients with MOC （50.0% vs 19.0%, P=0.11）. Median time to recurrent biliary obstruction was 188 days and median survival was 175 days. CONCLUSIONS： The large cell type stent can be used efficiently for bilateral SIS placement in malignant hilar obstruction. However, the risk of technical failure increases in patients with MOC, and caution is needed to prevent complications for these patients.

Combined treatment of refractory benign stricture after esophageal endoscopic mucosal dissection:A case report

BACKGROUND Endoscopic submucosal dissection(ESD)post-procedure stricture is a relatively common long-term complication following ESD treatment.A range of approaches has been implemented for the treatment of post-procedural stricture using endoscopic techniques such as endoscopic dilation,self-expandable metallic stent insertion,local steroid injection in the esophagus,oral steroid administration,radial incision and cutting(RIC).The actual efficacy of these different therapeutic options is highly variable,and uniform international standards for the prevention or treatment of stricture.CASE SUMMARY In this report,we describe the case of a 51-year-old male diagnosed with early esophageal cancer.To protect against esophageal stricture,the patient was administered oral steroids and underwent self-expandable metallic stent insertion for 45 d.Despite these interventions,stricture was detected at the lower edge of the stent following its removal.The patient remained refractory to multiple rounds of endoscopic bougie dilation treatment,and thus suffered from complex refractory benign esophageal stricture.As such,RIC combined with bougie dilation and steroid injection was employed to treat this patient more effectively,ultimately achieving satisfactory therapeutic efficacy.CONCLUSION Combination of RIC,dilation,and steroid injection can be safely and effectively implemented to treat cases of post-ESD refractory esophageal stricture.