Out of sight but kept in mind: complications and imitations of dropped gallstones.

OBJECTIVE: The purpose of this article is to describe the diagnostic pitfalls caused by dropped gallstones left in situ after laparoscopic cholecystectomy. CONCLUSION: Dropped gallstones may rarely become symptomatic, causing recurrent abscesses. Diagnosis is challenging due to unusual clinical presentations, myriad locations, and radiologically occult calculi. Even asymptomatic dropped gallstones may cause diagnostic confusion by masquerading as intraperitoneal neoplastic deposits. Radiologists should be aware of techniques for identifying and retrieving dropped gallstones and be wary of their complications and imitations in patients who have undergone laparoscopic cholecystectomy.

Long-term success of colonic stent insertion is influenced by indication but not by length of stent or site of obstruction.

INTRODUCTION: Stent insertion plays an important part in the management of acute colonic obstruction. There are limited data on factors influencing short- and long-term success. AIMS AND METHODS: We investigated indications, technical and clinical success rates, complication rates and the factors influencing them. Patients were identified from our prospective colonic stent database (2000-2008). RESULTS: One hundred and four stents were attempted in 96 patients (technical success rate, 83.3%). Clinical short-term success was observed in 74 (77.1%) patients. Follow-up data available for 57 patients showed clinical long-term success in 77% (44/57). Multiple logistic regression analysis showed a significant decline in technical success over the study period (p = 0.041). Patients with colonic malignancy had significantly higher long-term success rates (81%), compared to those with extra-colonic malignancies (43%) (p = 0.049). Length of stent and site of obstruction were not significant factors. Early complications occurred in 10%, and late complications, in 26.3% of cases. CONCLUSION: Colonic stent insertion provides symptom relief in over 70% when used as a long-term solution. Complication rates are high, and a significant minority of patients requires re-intervention. Obstruction caused by extra-colonic malignancy is far less likely to be permanently palliated by a stent, in comparison to colonic malignancy.

Management of benign biliary strictures.

Benign biliary strictures are most commonly a consequence of injury at laparoscopic cholecystectomy or fibrosis after biliary-enteric anastomosis. These strictures are notoriously difficult to treat and traditionally are managed by resection and fashioning of a choledocho- or hepato-jejunostomy. Promising results are being achieved with newer minimally invasive techniques using endoscopic or percutaneous dilatation and/or stenting and these are likely to play an increasing role in the management. Even low-grade biliary obstruction carries the risks of stone formation, ascending cholangitis and hepatic cirrhosis and it is important to identify and treat this group of patients. There is currently no consensus on which patient should have what type of procedure, and the full range of techniques may not be available in all hospitals. Careful assessment of the risks and likely benefits have to be made on an individual basis. This article reviews the current literature and discusses the options available. The techniques of endoscopic and percutaneous dilatation and stenting are described with evaluation of the likely success and complication rates and compared to the gold standard of biliary-enteric anastomosis.

Gastroduodenal stenting.

Palliative procedures for patients with malignant gastroduodenal obstruction must be readily available, have a rapid onset of action, and be well tolerated by a patient with terminal cancer. Laparoscopic gastroenterostomy and insertion of self-expanding stents are emerging as the current methods of choice.An increasing number of dedicated enteral stents with different properties are now available. These can be placed under fluoroscopic guidance alone or with the help of an endoscope. Endoscopic placement has several advantages but requires good collaboration between the endoscopists and the radiology department. Appropriate imaging and work-up of each case at multidisciplinary meetings is required. Coexisting biliary obstruction may be dealt with endoscopically, but frequently requires percutaneous biliary stent placement prior to duodenal stenting. Reintervention is required in up to 25% of patients, usually due to stent occlusion by further tumor growth. This article suggests strategies for patient assessment, procedure planning, and stent insertion.

Effectiveness of open versus antireflux stents for palliation of distal esophageal carcinoma and prevention of symptomatic gastroesophageal reflux.

PURPOSE: To compare the effectiveness of an antireflux stent with that of a standard open stent in preventing symptoms of gastroesophageal reflux in patients with inoperable distal esophageal cancer. MATERIALS AND METHODS: Fifty consecutive patients with inoperable distal esophageal tumors underwent placement of either a standard open or an antireflux stent across the cardia. Stents were allocated randomly before assessment of the stricture. All patients were followed up prospectively by the departmental research nurses. Technical and clinical success, reflux symptoms, complications, and reintervention rates were assessed. P values of observed differences were calculated by using the chi(2) and log-rank tests as appropriate. RESULTS: The technical success rate was 100%. Improvement in dysphagia was identical in both groups (three points on a five-point scale). Twenty-four (96%) of 25 patients with standard open stents had symptoms of esophageal reflux; 19 (76%) of 25 required treatment. Three (12%) of 25 patients with antireflux stents reported esophageal reflux; one (4%) of 25 required treatment. This difference was significant (P <.001). There was no significant difference in survival, complications, or reintervention rate. One case of late esophageal perforation occurred in each group. One patient died of aspiration within 24 hours after insertion of a standard open stent; no procedure-related deaths occurred with the antireflux stent. CONCLUSION: This antireflux stent is as safe and effective as the standard open stent in relieving malignant dysphagia and was successful in reducing symptomatic gastroesophageal reflux.