The utility of self-expanding metal stents in benign biliary strictures- a retrospective case series.

BACKGROUND: Benign biliary strictures can have a significant negative impact on patient quality of life. There are several modalities which can be utilized with the goal of stricture resolution. These techniques include balloon dilatation, placement of multiple plastic stents and more recently, the use of metal stents. The aim of this study was to evaluate the local success of self-expanding metal stents in successfully resolving benign biliary strictures. METHODS: This was a single institution, retrospective case series. Patients included in our study were patients who underwent endoscopic retrograde cholangiopancreatography with placement of self expanding metal stents for benign biliary strictures at our institution between 2016-2022. Patients were excluded for the following: malignant stricture, and inability to successfully place metal stent. Data was evaluated using two-sided t-test with 95% confidence interval. RESULTS: A total of 31 patients underwent placement of 43 self-expanding metal stents and met inclusion criteria. Mean age of patients was 59 ± 10 years, and were largely male (74.2% vs. 25.8%). Most strictures were anastomotic stricture post liver transplant (87.1%), while the remainder were secondary to chronic pancreatitis (12.9%). Complications of stent placement included cholangitis (18.6%), pancreatitis (2.3%), stent migration (20.9%), and inability to retrieve stent (4.7%). There was successful stricture resolution in 73.5% of patients with anastomotic stricture and 33.3% of patients with stricture secondary to pancreatitis. Resolution was more likely if stent duration was > / = 180 days (73.3% vs. 44.4%, p < 0.05). There was no demonstrated added benefit when stent duration was > / = 365 days (75% vs. 60.9%, p = 0.64). CONCLUSIONS: This study demonstrates that self expanding metal stents are a safe and effective treatment for benign biliary strictures, with outcomes comparable to plastic stents with fewer interventions. This study indicates that the optimal duration to allow for stricture resolution is 180-365 days.

Extent of Lymph Node Harvest: A Retrospective Cohort Comparison of Intracorporeal Versus Extracorporeal Anastomosis in Right Hemicolectomy.

Background: Minimally invasive surgery has been demonstrated to have clear advantages in colon cancer management, with a decrease in the morbidity and mortality associated with surgery. With the introduction of intracorporeal anastomosis (ICA), the entire mesenteric dissection and division is performed under vision laparoscopically and may lead to superior lymph node harvest. The aim of our study is to evaluate lymph node harvest in patients undergoing totally laparoscopic right hemicolectomy with ICA compared to laparoscopic-assisted right hemicolectomy with extracorporeal anastomosis (ECA). Methods: This is a single institution retrospective cohort study. Eligible patients underwent laparoscopic right hemicolectomy at our institution between 2012 and 2022. Patients were identified using a hospital database, and surgeon office databases. Patients included underwent laparoscopic right hemicolectomy for neoplastic lesions (colon cancer/unresectable polyps), or benign etiologies. We excluded patients who underwent laparotomy (intra-operative conversion), resection without anastomosis, resection for IBD, or lack of documented lymph node number. Data were compared using two-sided t-test evaluation with a 95% confidence interval. Results: A total of 679 patients were included, 493 ECA (72.6%) and 186 ICA (27.4%). Patient demographics (age, biologic sex, American Society of Anesthesiologists and body mass index) were not significantly different. Lymph node harvest was significantly higher in those with ICA (24 ± 14 versus 21 ± 1, P < .05). In subgroup analysis, this difference was maintained in patients with malignant processes (27 ± 14 versus 23 ± 10, P < .05). Conclusions: In our experience, ICA has higher lymph node harvest in comparison to ECA. This may improve outcomes and options for adjuvant therapies in malignant indications.

Laparoscopic Right Hemicolectomy for Inflammatory Bowel Disease: Is Intracorporeal Anastomosis Feasible? A Retrospective Cohort Comparison Study.

Background: Inflammatory bowel disease (IBD) affects all ages and backgrounds, and many individuals require surgical intervention during their disease course. The adoption of laparoscopic techniques in this patient population has been slow, including intracorporeal anastomosis (ICA). The aim of our study was to determine if ICA was feasible and safe in patients with IBD undergoing laparoscopic right hemicolectomy (LRHC). Methods: This is a retrospective, single institution cohort study of elective and emergent cases of LRHC at a single academic center. Patients included underwent LRHC or ileocolic resection for IBD. Exclusion criteria: conversion to laparotomy, resection without anastomosis, or unconfirmed diagnosis of IBD. Main outcomes studied were anastomotic leak rate, surgical site infection (SSI), postoperative length of stay, 30-day readmission/reoperation, and operative time. Secondary outcomes were incisional hernia rates and rates of disease recurrence. Results: A total of 70 patients were included, 12 underwent ICA and 58 extracorporeal anastomosis. Anastomotic leak rate (intracorporeal 8.3% [n = 1], extracorporeal 8.6% [n = 5], P = .97), and SSI rates (intracorporeal 0%, extracorporeal 6.9% [n = 4], P = .36) were similar. Mean postoperative length of stay, rates of 30-day readmission/reoperation and diagnosis of hernia at 1 year were not significantly different. Rates of IBD recurrence and location of recurrence at 1 year were similar. However, operative time was significantly longer in those undergoing ICA (intracorporeal 187 minutes versus extracorporeal 139 minutes, P = < .05). Conclusions: ICA is a safe option in patients with IBD undergoing LRHC.

Bacterial presence on flexible endoscopes vs time since disinfection.

AIM: To correlate the length of endoscope hang time and number of bacteria cultured prior to use. METHODS: Prospectively, we cultured specimens from 19 gastroscopes, 24 colonoscopes and 5 side viewing duodenoscopes during the period of 2011 to 2015. A total of 164 results had complete data denoting date of cleansing, number of days stored and culture results. All scopes underwent initial cleaning in the endoscopy suite utilizing tap water, and then manually cleaned and flushed. High level disinfection was achieved with a Medivator© DSD (Medivator Inc., United States) automated endoscope reprocessor following manufacturer instructions, with Glutacide® (Pharmax Limited, Canada), a 2% glutaraldehyde solution. After disinfection, all scopes were stored in dust free, unfiltered commercial cabinets for up to 7 d. Prior to use, all scopes were sampled and plated on sheep blood agar for 48 h; the colony count was obtained from each plate. The length of endoscope hang time and bacterial load was analyzed utilizing unpaired t-tests. The overall percentage of positive and negative cultures for each type of endoscope was also calculated. RESULTS: All culture results were within the acceptable range (less than 200 cfu/mL). One colonoscope cultured 80 cfu/mL after hanging for 1 d, which was the highest count. ERCP scopes cultured at most 10 cfu, this occurred after 2 and 7 d, and gastroscopes cultured 50 cfu/mL at most, at 1 d. Most cultures were negative for growth, irrespective of the length of hang time. Furthermore, all scopes, with the exception of one colonoscope which had two positive cultures (each of 10 cfu/mL), had at most one positive culture. There was no significant difference in the number of bacteria cultured after 1 d compared to 7 d when all scopes were combined (day 2: P = 0.515; day 3: P = identical; day 4: P = 0.071; day 5: P = 0.470; day 6: P = 0.584; day 7: P = 0.575). There was also no significant difference in the number of bacteria cultured after 1 day compared to 7 d for gastroscopes (day 2: P = 0.895; day 3: P = identical; day 4: P = identical; day 5: P = 0.893; day 6: P = identical; day 7: P = 0.756), colonoscopes (day 2: P = 0.489; day 4: P = 0.493; day 5: P = 0.324; day 6: P = 0.526; day 7: P = identical), or ERCP scopes (day 2: P = identical; day 7: P = 0.685). CONCLUSION: There is no correlation between hang time and bacterial load. Endoscopes do not need to be reprocessed if reused within a period of 7 d.