Fully covered self-expanding metal stents in the management of difficult common bile duct stones.

BACKGROUND AND OBJECTIVES: plastic biliary stents are often used after an ERCP session without complete common bile duct stones (CBDS) extraction. Sometimes, the volume of biliary drainage with these stents may be insufficient. We present our experience with the use of fully covered self-expanding metal stents (FCSEMS) in the setting of incomplete CBDS extraction. PATIENTS AND METHODS: after an ERCP session with difficult CBDS not completely removed, biliary FCSEMS (Wallflex) were inserted in some patients when it was deemed that biliary sphincterotomy and a single plastic stent would not provide an adequate drainage. RESULTS: a retrospective study was performed. Biliary FCSEMS were inserted in 29 patients, mean age 81 years. CBDS could not be extracted through a biliary sphincterotomy due to its large size (n = 18) or because of the presence of inflammatory distal strictures (n = 11). The greatest biliary drainage with shortest ERCP time was considered mandatory due to clinical instability of patients and/or poor tolerance to conscious sedation administered by the endoscopist. Successful biliary drainage was obtained in all cases. FCSEMS were removed after a median of 199.5 days in 16 patients with a complete CBDS extraction in 15 (93.7%). FCSEMS were not removed in the remaining 13 patients due to their clinical condition, and a wait-and-see strategy was undertaken. CONCLUSIONS: in selected cases, utilization of removable FCSEMS can be a good option for a quick and adequate biliary drainage in the setting of difficult CBDS. Because of the higher cost of these stents its use needs to be individualized.

Diagnostic yield and impact of capsule endoscopy on management of patients with gastrointestinal bleeding of obscure origin.

This study assessed diagnostic yield and impact of capsule endoscopy on patient management. Seventy-five patients with obscure gastrointestinal bleeding were included. Clinical and followup information was collected by review of patient records and with personal contact with the referring physicians. All previous clinical information and interventions after capsule endoscopy and clinical outcome were noted. The indication was obscure-overt gastrointestinal bleeding in 36 patients (48%) and obscure-occult gastrointestinal bleeding in 39 patients (52%). Overall diagnostic yield was 66.7% considering relevant lesions. Followup was available in 31 patients. Capsule endoscopy changed clinical management in 61.4%. Multivariate analysis showed that patients with another potential source of bleeding and patients whose onset was hematochezia were not good candidates for capsule endoscopy. Capsule endoscopy has a high diagnostic yield and a positive influence on clinical management in a high proportion of patients with obscure gastrointestinal bleeding.