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Buyruk AM, Erdoğan Ç, Tekin F, Turan İ, Özütemiz Ö, Ersöz G. The use of fully covered self-expandable metal stents in the endoscopic treatment of portal cavernoma cholangiopathy. BMC Gastroenterol 2023; 23:414. [PMID: 38017393 PMCID: PMC10683077 DOI: 10.1186/s12876-023-03042-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 11/08/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND AND AIMS There are different therapeutic approaches for biliary strictures and reducing portal hypertension in patients with symptomatic portal cavernoma cholangiopathy (PCC). Endoscopic treatment includes endoscopic biliary sphincterotomy (EST), dilation of stricture with a biliary balloon, placement of plastic stent(s) and stone extraction. Fully covered self-expandable metal stent (FCSEMS) is placed as a rescuer in case of haemobilia seen after EST, dilation of stricture and removal of plastic stent rather than the stricture treatment itself. In this retrospective observational study, we sought to assess the clinical outcomes of FCSEMS as the initial treatment for PCC-related biliary strictures. MATERIALS AND METHODS Twelve symptomatic patients with PCC both clinically and radiologically between July 2009 and February 2019 were examined. Magnetic resonance cholangiopancreatography (MRCP) and cholangiography were employed as the diagnostic imaging methods. Chandra-Sarin classification was used to distinguish between biliary abnormalities in terms of localization. Llop classification was used to group biliary abnormalities associated with PCC. Endoscopic partial sphincterotomy was performed in all the patients. If patients with dominant strictures 6-8-mm balloon dilation was first performed. This was followed by removal of the stones if exist. Finally, FCSEMS placed. The stents were removed 6-12 weeks later. RESULTS The mean age of the patients was 40.9 ± 10.3 years, and 91.6% of the patients were male. Majority of the patients (n = 9) were noncirrhotic. Endoscopic retrograde cholangiopancreatography (ERCP) findings showed that 11 of the 12 patients were Chandra Type I and one was Chandra Type IIIa. All the 12 patients were Llop Grade 3. All patients had biliary involvement in the form of strictures. Stent placement was successful in all patients. FCSEMSs were retained for a median period of 45 days (30-60). Seven (58.3%) patients developed acute cholecystitis. There was no occurrence of bleeding or other complications associated with FCSEMS replacement or removal. All patients were asymptomatic during median 3 years (1-10) follow up period. CONCLUSIONS FCSEMS placement is an effective method in biliary strictures in case of PCC. Acute cholecystitis is encountered frequently after FCSEMS, but majority of patients respond to the medical treatment. Patients should be followed in terms of the relapse of biliary strictures.
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Affiliation(s)
| | - Çağdaş Erdoğan
- Department of Gastroenterology, University of Health Sciences, Ankara Etlik City Hospital, Ankara, Turkey.
| | - Fatih Tekin
- Department of Gastroenterology, Ege University School of Medicine, İzmir, Turkey
| | - İlker Turan
- Department of Gastroenterology, Ege University School of Medicine, İzmir, Turkey
| | - Ömer Özütemiz
- Department of Gastroenterology, Ege University School of Medicine, İzmir, Turkey
| | - Galip Ersöz
- Department of Gastroenterology, Ege University School of Medicine, İzmir, Turkey
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Maydeo A, Kamat N, Dalal A, Patil G. Advances in the Management of Pain in Chronic Pancreatitis. Curr Gastroenterol Rep 2023; 25:260-266. [PMID: 37713043 DOI: 10.1007/s11894-023-00898-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 09/16/2023]
Abstract
PURPOSE OF REVIEW The data on recent advances in managing chronic pancreatitis (CP) pain is limited. This review highlights the role of endotherapy and the advances in the overall management of pain in CP. RECENT FINDINGS Of late, pancreatic biodegradable stents have been used in endotherapy with appreciable success. These include slow, medium, and fast degrading stents, which optimize the overall management of CP and could prevent the need for multiple procedures. Endoscopic ultrasound-guided celiac plexus block is reserved in selected patients to treat debilitating pain. Total pancreatectomy with islet autotransplantation in small duct disease has shown promising results. The indications for treating pain in CP with endoscopy and surgery need to be better defined. The complexity of pain control due to the incomplete understanding of pathomorphology makes the management of CP challenging. The current treatment methods are still evolving. Therapy aims to reduce pain, optimize recovery, maintain quality of life, and meet postoperative needs. Initial management includes lifestyle modification, nutrition optimization, risk factor reduction with abstinence from alcohol, cessation of tobacco and smoking. Supportive medical management involves the judicial use of analgesics, neuromodulators, antioxidants, pancreatic enzyme replacement for insufficiency, and diabetes management. Patients with intractable pain are ideal for therapeutic intervention. Being less invasive with an acceptable complication rate makes endotherapy the preferred first-line treatment. If found to be cost-effective, biodegradable stents can reduce the overall cost. Unfortunately, if patients remain symptomatic, surgery is preferred in case of failure or recurrence. For optimal results, appropriate patient selection is vital to maximizing outcomes.
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Affiliation(s)
- Amit Maydeo
- Institute of Gastrosciences, Sir H. N. Reliance Foundation Hospital and Research Centre, Girgaon, Mumbai, Maharashtra, India, 400004.
| | - Nagesh Kamat
- Institute of Gastrosciences, Sir H. N. Reliance Foundation Hospital and Research Centre, Girgaon, Mumbai, Maharashtra, India, 400004
| | - Ankit Dalal
- Institute of Gastrosciences, Sir H. N. Reliance Foundation Hospital and Research Centre, Girgaon, Mumbai, Maharashtra, India, 400004
| | - Gaurav Patil
- Institute of Gastrosciences, Sir H. N. Reliance Foundation Hospital and Research Centre, Girgaon, Mumbai, Maharashtra, India, 400004
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Abstract
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.
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Affiliation(s)
- Robert Lam
- Department of Medicine, Yale University School of Medicine, New Haven, CT 06520, United States
| | - Thiruvengadam Muniraj
- Department of Medicine, Yale University School of Medicine, New Haven, CT 06520, United States
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De Gregorio MA, Criado E, Guirola JA, Alvarez-Arranz E, Pérez-Lafuente M, Barrufet M, Ferrer-Puchol MD, Lopez-Minguez S, Urbano J, Lanciego C, Aguinaga A, Capel A, Ponce-Dorrego MD, Gregorio A. Absorbable stents for treatment of benign biliary strictures: long-term follow-up in the prospective Spanish registry. Eur Radiol 2020; 30:4486-4495. [PMID: 32221684 DOI: 10.1007/s00330-020-06797-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 03/01/2020] [Accepted: 03/09/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Benign strictures of the bile duct may be difficult to treat endoscopically due to altered bowel anatomy. Furthermore, recurrence of stenosis and symptoms remains high. The aim of the Spanish Prospective Registry BiELLA study was to investigate the safety and efficacy of absorbable stents in the treatment of benign biliary strictures and their outcomes on the medium and long-term follow-up. METHODS A prospective, multicenter, observational, non-randomized study (the BiELLA study) was conducted from January 2014 to September 2018. One hundred fifty-nine patients with benign biliary strictures, mostly postsurgical, were enrolled for implantation of absorbable biliary stents in the 11 participating Spanish tertiary hospitals. The average patient follow-up was 45.4 ± 15.9 months (range, 12-60 months). The follow-up data included symptoms, biochemical parameters, and ultrasound images at 1, 6, and 12 months and then yearly for up to 60 months. RESULTS The immediate technical and clinical success rates were 100%. In all patients, stent placement resulted in improvement of clinical symptoms and biochemical parameters. The primary mean patency for stent was 86.7, 79.6, and 78.9% at 12, 36, and 60 months, respectively (95% CI). Biliary restenosis and occlusion occurred in 40 (26.6%) patients. Of the 40 patients, 18 (12%) patients were treated with a second stent and 22 (14.6%) patients had operative repair of the recurrent strictures. There were no major complications associated with stent implantation. CONCLUSIONS Implantation of an absorbable polydioxanone biliary stent is safe and effective for treatment of benign biliary strictures refractory to balloon dilatation or other biliary intervention. KEY POINTS • Percutaneous implantation of biodegradable prostheses for the treatment of benign postsurgical biliary strictures is a safe and effective procedure. • More than 75% of the patients presented patency of the stented biliary tree at 5 years follow-up. • Absorbable stents improved clinical symptoms and signs (jaundice, itching, fever), and laboratory parameters in a few days after stent placement.
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Affiliation(s)
- Miguel A De Gregorio
- Interventional Radiology Research Group (GITMI), University of Zaragoza, Zaragoza, Spain
| | - Eva Criado
- Interventional Radiology Unit, UDIAT-Centre Diagnòstic, Hospital Universitario Parc Tauli Sabadell, Medicine Department Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Jose A Guirola
- Interventional Radiology Research Group (GITMI), University of Zaragoza, Zaragoza, Spain
| | - Enrique Alvarez-Arranz
- Interventional Radiology Research Group (GITMI), University of Zaragoza, Zaragoza, Spain.
| | | | - Marta Barrufet
- Interventional Radiology Unit, Hospital Clínic i Provincial, Barcelona, Spain
| | - Maria D Ferrer-Puchol
- Interventional Radiology Unit, Hospital Universitario La Ribera, Alzira, Valencia, Spain
| | - Sandra Lopez-Minguez
- Interventional Radiology Research Group (GITMI), University of Zaragoza, Zaragoza, Spain
| | - Jose Urbano
- Interventional Radiology Unit, Hospitales Vithas, Madrid, Spain
| | - Carlos Lanciego
- Interventional Radiology Unit, Hospital Universitario Virgen de la Salud, Toledo, Spain
| | - Alexander Aguinaga
- Interventional Radiology Unit, Hospital Universitario de Cruces, Bilbao, Spain
| | - Antonio Capel
- Interventional Radiology Unit, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | | | - Abel Gregorio
- Interventional Radiology Unit, Hospital de Denia Marina Salud, Alicante, Spain
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Park JS, Jeong S, Kobayashi M, Lee DH. Safety, efficacy, and removability of a fully covered multi-hole metal stent in a swine model of hilar biliary stricture: a feasibility study. Endosc Int Open 2019; 7:E498-E503. [PMID: 31041366 PMCID: PMC6447406 DOI: 10.1055/a-0846-0775] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 10/08/2018] [Indexed: 12/20/2022] Open
Abstract
Background and study aims Use of fully covered self-expandable metal stents (FCSEMS) for biliary drainage of malignant hilar biliary strictures is limited because of risk of cholangitis due to side branch obstruction. The aim of this study was to evaluate the safety and efficacy of unilateral placement of a multi-hole FCSEMS (FCSEMS-MH), which had a 2.5-mm hole in the center of the membrane on each cavity, in a swine model of hilar biliary stricture. Materials and methods Six female mini pigs were included in this prospective study. The hilar biliary stricture model was prepared using an endobiliary radiofrequency ablation. FCSEMS-MHs were endoscopically inserted into the peri-hilar bile duct of all the animals. Outcomes were assessed in terms of adverse events (AEs) including cholangitis, stent patency, stent migration, and endoscopic stent removability for 1 month after stenting. Results In terms of hilar biliary stricture types, two animals were of Bismuth type I and four were of type II. Technical success rate for endoscopic metal stenting was 100 % (6/6), and the functional success rate, which was evaluated 7 days after stent insertion, was also 100 % (5/5). The immediate overall AE rate was 0 %. There was no procedure-related mortality and stent migration did not occur in any animal during the 4-week stent indwelling period. Stents were removed from all six animals at 4 weeks post-stenting. Conclusion Unilateral placement of FCSEMS-MH might be safe and effect for swine hilar biliary stricture models. However, long-term follow-up and comparative studies are needed to verify the usefulness of this stent.
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Affiliation(s)
- Jin-Seok Park
- Digestive Disease Center, Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea.,National Center of Efficacy Evaluation for the Development of Health Products Targeting Digestive Disorders (NCEED), Incheon, Republic of Korea
| | - Seok Jeong
- Digestive Disease Center, Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea.,National Center of Efficacy Evaluation for the Development of Health Products Targeting Digestive Disorders (NCEED), Incheon, Republic of Korea,Corresponding author Seok Jeong, MD Division of GastroenterologyDepartment of Internal MedicineInha University Hospital27 Inhang-ro, Jung-gu, Incheon, 22332Republic of Korea+82-32-890-2549
| | - Makoto Kobayashi
- Department of Gastroenterology, Yokkaichi Municipal Hospital, Yokkaichi, Japan
| | - Don Haeng Lee
- Digestive Disease Center, Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea.,National Center of Efficacy Evaluation for the Development of Health Products Targeting Digestive Disorders (NCEED), Incheon, Republic of Korea,Utah-Inha DDS & Advanced Therapeutics Research Center, Incheon, Republic of Korea
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Han MG, Cho E, Park CH, Jun CH, Park SY. Self-expandable metal stents for choledocholithiasis in Billroth II gastrectomy patients. Hepatobiliary Pancreat Dis Int 2018; 17:546-52. [PMID: 30126827 DOI: 10.1016/j.hbpd.2018.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 07/26/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Efficient ampullary intervention is essential for endoscopic retrograde cholangiopancreatography (ERCP) in patients with a prior Billroth II gastrectomy. We retrospectively evaluated the safety and effectiveness of ampullary intervention using fully covered self-expandable metal stents (FCSEMSs) for the management of common bile duct (CBD) stones in a subset of patients with a history of Billroth II gastrectomy. METHODS This retrospective analysis involved patients with a prior Billroth II gastrectomy who underwent ampullary intervention with FCSEMSs for the management of CBD stones. The factors associated with FCSEMSs placement, treatment success, and procedural complications were analyzed. RESULTS A group of 15 patients (10 males; median age, 78 years) underwent biliary metal stent placement for high degree of CBD angulation (6), small or flat papilla with unclear margin (5), current use of double antiplatelet agents or an anticoagulant (2), unwanted instrumentation of the cystic duct (1), and insecure position of the scope (1). Ampullary intervention with FCSEMSs was successful in all patients. After dilating the ampulla of Vater and building a durable conduit with FCSEMSs immediately, CBD stones were removed successfully from all patients in a single session. A mild post-ERCP pancreatitis occurred in one patient, who recovered without complications. CONCLUSION Ampullary intervention with FCSEMSs is safe and effective for the management of CBD stones in a subset of patients with a history of Billroth II gastrectomy.
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Bray MS, Borgert AJ, Folkers ME, Kothari SN. Outcome and management of endoscopic retrograde cholangiopancreatography perforations: A community perspective. Am J Surg 2017; 214:69-73. [PMID: 28173939 DOI: 10.1016/j.amjsurg.2017.01.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 01/20/2017] [Accepted: 01/29/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) carries a small but significant risk of perforation. Recent data suggest that select patients can be managed non-operatively. We sought to evaluate the management of ERCP perforations at our community medical center. METHODS ERCPs performed from 2004 to 2015 were reviewed. RESULTS Twenty-one of 2423 patients who underwent ERCP had a perforation (0.9%). ERCP procedures included balloon sweep with/without sphincterotomy and pancreatic duct stent (71%), common bile duct brushing (10%), and pancreatic duct stenting (5%). Duodenal diverticula were present in 3 (14%), and altered anatomy was present in 6 (29%). Seventeen patients were treated nonoperatively; 3 (14%) underwent percutaneous drain placement. Two patients failed nonoperative treatment and required surgery. Four patients required ICU stay, and median post-ERCP LOS was 5 days. The 30-day mortality rate was 1/21 (4.8%). CONCLUSIONS Perforations remain a rare, but serious, complication of ERCPs. Nonoperative management is highly successful in carefully selected patients. Early recognition with initiation of antibiotics is paramount. Our community-based practice patterns are similar to those previously published for successful nonoperative management of ERCP perforations.
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Affiliation(s)
- Mallory S Bray
- Department of Medical Education, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Andrew J Borgert
- Department of Medical Research, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Milan E Folkers
- Department of Gastroenterology, Gundersen Health System, La Crosse, WI, USA
| | - Shanu N Kothari
- Department of General Surgery, Gundersen Health System, La Crosse, WI, USA.
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Weigt J, Kandulski A, Malfertheiner P. Anatomy-shaped design of a fully-covered, biliary, self-expandable metal stent for treatment of benign distal biliary strictures. Endosc Int Open 2016; 4:E79-82. [PMID: 26793789 PMCID: PMC4713183 DOI: 10.1055/s-0034-1393583] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND AND STUDY AIMS The treatment success of benign biliary strictures with fully covered metal stents (CSEMS) is altered by high stent dislocation rates. We aimed to evaluate a new stent design to prevent dislocation. PATIENTS AND METHODS Patients with benign biliary strictures were treated with a newly designed double-coned stent (dcSEMS). Mechanical analysis of the new stent was performed and it was compared with a cylindrical stent. RESULTS A total of 13 dcCSEMS were implanted in 11 patients (2 female, 9 male, median age 47, range 33 - 71). All patients had distal biliary strictures due to chronic pancreatitis. No stent migration occurred. In all but one patient the stents were removed. One patient refused stent extraction and was lost to follow up. Stent occlusion occurred twice leading to cholangitis in both cases. The duration of stent treatment was 170 days (range 61 - 254). After extraction only one patient had early recurrent stricture and received the same stent again. Three stents showed minimal tissue granulation at the papilla. One stent presented ingrowth at the proximal end and was removed after implantation of a second fully covered stent. Mechanical examination revealed significantly lower radial expansion force of the new stent as compared to the cylindrical stent. CONCLUSIONS The new stent design has a low rate of migration. Biomechanical properties may explain this effect.
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Affiliation(s)
- Jochen Weigt
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University, Magdeburg, Germany
| | - Arne Kandulski
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University, Magdeburg, Germany
| | - Peter Malfertheiner
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University, Magdeburg, Germany
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Petersen BT. Use of Covered Self-Expandable Metal Stents in the Management of Nonstricture Biliary Disorders. Gastroenterol Hepatol (N Y) 2015; 11:689-691. [PMID: 27330496 PMCID: PMC4849521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Bret T Petersen
- Professor of Medicine Division of Gastroenterology and Hepatology Mayo Clinic Rochester, Minnesota
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10
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Mangiavillano B, Pagano N, Baron TH, Luigiano C. Outcome of stenting in biliary and pancreatic benign and malignant diseases: A comprehensive review. World J Gastroenterol 2015; 21:9038-9054. [PMID: 26290631 PMCID: PMC4533036 DOI: 10.3748/wjg.v21.i30.9038] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 05/04/2015] [Accepted: 07/08/2015] [Indexed: 02/07/2023] Open
Abstract
Endoscopic stenting has become a widely method for the management of various malignant and benign pancreatico-biliary disorders. Biliary and pancreatic stents are devices made of plastic or metal used primarily to establish patency of an obstructed bile or pancreatic duct and may also be used to treat biliary or pancreatic leaks, pancreatic fluid collections and to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis. In this review, relevant literature search and expert opinions have been used to evaluate the outcome of stenting in biliary and pancreatic benign and malignant diseases.
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Devière J, Nageshwar Reddy D, Püspök A, Ponchon T, Bruno MJ, Bourke MJ, Neuhaus H, Roy A, González-Huix Lladó F, Barkun AN, Kortan PP, Navarrete C, Peetermans J, Blero D, Lakhtakia S, Dolak W, Lepilliez V, Poley JW, Tringali A, Costamagna G. Successful management of benign biliary strictures with fully covered self-expanding metal stents. Gastroenterology 2014; 147:385-95; quiz e15. [PMID: 24801350 DOI: 10.1053/j.gastro.2014.04.043] [Citation(s) in RCA: 157] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 04/03/2014] [Accepted: 04/29/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Fully covered self-expanding metal stents (FCSEMS) are gaining acceptance for the treatment of benign biliary strictures. We performed a large prospective multinational study to study the ability to remove these stents after extended indwell and the frequency and durability of stricture resolution. METHODS In a nonrandomized study at 13 centers in 11 countries, 187 patients with benign biliary strictures received FCSEMS. Removal was scheduled at 10-12 months for patients with chronic pancreatitis or cholecystectomy and at 4-6 months for patients who received liver transplants. The primary outcome measure was removal success, defined as either scheduled endoscopic removal of the stent with no removal-related serious adverse events or spontaneous stent passage without the need for immediate restenting. RESULTS Endoscopic removal of FCSEMS was not performed for 10 patients because of death (from unrelated causes), withdrawal of consent, or switch to palliative treatment. For the remaining 177 patients, removal success was accomplished in 74.6% (95% confidence interval [CI], 67.5%-80.8%). Removal success was more frequent in the chronic pancreatitis group (80.5%) than in the liver transplantation (63.4%) or cholecystectomy (61.1%) groups (P = .017). FCSEMS were removed by endoscopy from all patients in whom this procedure was attempted. Stricture resolution without restenting upon FCSEMS removal occurred in 76.3% of patients (95% CI, 69.3%-82.3%). The rate of resolution was lower in patients with FCSEMS migration (odds ratio, 0.22; 95% CI, 0.11-0.46). Over a median follow-up period of 20.3 months (interquartile range, 12.9-24.3 mo), the rate of stricture recurrence was 14.8% (95% CI, 8.2%-20.9%). Stent- or removal-related serious adverse events, most often cholangitis, occurred in 27.3% of patients. There was no stent- or removal-related mortality. CONCLUSIONS In a large prospective multinational study, removal success of FCSEMS after extended indwell and stricture resolution were achieved for approximately 75% of patients. ClincialTrials.gov number, NCT01014390.
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Affiliation(s)
- Jacques Devière
- Service de Gastro-Entérologie et d'Hépato-Pancréatologie, Université Libre de Bruxelles, Hôpital Erasme, Brussels, Belgium.
| | - D Nageshwar Reddy
- Gastroenterology and Therapeutic Endoscopy, Asian Institute of Gastroenterology, Hyderabad, India
| | - Andreas Püspök
- Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Vienna, Austria
| | - Thierry Ponchon
- Service de Gastroentérologie et d'Endoscopie Digestive, Hôpital Edouard Herriot, Lyon, France
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, University of Rotterdam, Rotterdam, The Netherlands
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Horst Neuhaus
- Medizinische Klinik, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - André Roy
- Département de Chirurgie, Hôpital Saint-Luc, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Ferrán González-Huix Lladó
- Unidad de Endoscopia, Servicio de Aparato Digestivo, Hospital Universitari Doctor Josep Trueta, Girona, Catalunya, Spain
| | - Alan N Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, Montréal, Québec, Canada
| | - Paul P Kortan
- Division of Gastroenterology, Centre for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Claudio Navarrete
- Servicio de Endoscopía, Clínica Alemana de Santiago, Santiago, Chile
| | - Joyce Peetermans
- Endoscopy Division, Boston Scientific Corp, Natick, Massachusetts
| | - Daniel Blero
- Service de Gastro-Entérologie et d'Hépato-Pancréatologie, Université Libre de Bruxelles, Hôpital Erasme, Brussels, Belgium
| | - Sundeep Lakhtakia
- Gastroenterology and Therapeutic Endoscopy, Asian Institute of Gastroenterology, Hyderabad, India
| | - Werner Dolak
- Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Vienna, Austria
| | - Vincent Lepilliez
- Service de Gastroentérologie et d'Endoscopie Digestive, Hôpital Edouard Herriot, Lyon, France
| | - Jan W Poley
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, University of Rotterdam, Rotterdam, The Netherlands
| | - Andrea Tringali
- L'Unità Operativa di Endoscopia Digestiva Chirurgica, Policlinico Agostino Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Guido Costamagna
- L'Unità Operativa di Endoscopia Digestiva Chirurgica, Policlinico Agostino Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy
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Abstract
The majority of recent studies of benign biliary strictures (BBSs) have reported on treatment of stenotic injuries following cholecystectomy, orthotopic liver transplantation, living donor liver transplantation, chronic pancreatitis, and different inflammatory conditions such as common bile-duct-related strictures. Information about previous surgical procedures is very important for making a BBS diagnosis. Diagnostic tools for indeterminate strictures have increased to include (1) highly specialized cytological techniques such as fluorescence in situ hybridization, (2) cholangioscopy, and (3) endoscopic ultrasound with fine needle aspiration (FNA) and intraductal ultrasound. Magnetic resonance cholangiopancreatography before endoscopic retrograde cholangiopancreatography (ERCP) usually provides an adequate map to plan the endoscopic therapy. After traversing the stricture with a guidewire and, occasionally, performing balloon dilatation, plastic stents continue to be the basic endotherapy, trying to insert the maximum possible number, with an exchange every 3 months during a 12-month period. Progressive stenting requires a median number of five ERCPs; therefore, it is technically demanding and burdensome but has an average of 80% long-term durable stricture dilation. For not-hilar BBS, fully covered self-expanding metal stents (FCSEMSs) are emerging as a promising therapy needing fewer of the endoscopist's technical skills and reducing ERCP procedures and, probably, costs. To equal a 10-mm diameter provided by a single FCSEMS, about three plastic stents placed side-by-side are needed. Manufacturers are working to improve FCSEMS designs to reduce migration rate and to allow an easy extraction after several months in place. Many studies have tried to show reproducible protocols for the duration of FCSEMS therapy and the results in different types of BBSs.
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Affiliation(s)
- Jesús García-Cano
- Department of Digestive Diseases, Hospital Virgen de la Luz, 16002 Cuenca, Spain.
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