Fluoroscopy-Guided Peroral Placement of a Self-Expandable Metallic Stent for Malignant Jejunal Obstruction in a Non-surgically Altered Stomach.

Malignant small bowel obstruction is a common and distressing complication in advanced cancer patients. Recently, stent placement was reported to be a safe and effective alternative treatment. However, there are only a few case reports associated with stent placement in malignant jejunal obstruction. Furthermore, most patients had a history of gastrectomy before stent placement, which shortens the catheterization pathway. In our case series, we present five cases of malignant proximal jejunal obstruction in a non-surgically altered stomach in the management of fluoroscopy-guided self-expandable metallic stent placement and discuss the interventional management and clinical outcomes. LEVEL OF EVIDENCE: Level 4, Case Series.

High sustained virologic response rate using generic directly acting antivirals in the treatment of chronic hepatitis C virus Egyptian patients: single-center experience.

BACKGROUND: Hepatitis C virus (HCV) is a major health problem in Egypt, with a high prevalence of genotype 4. AIM: This study aimed to evaluate the safety and efficacy of generic sofosbuvir (SOF) plus generic daclatasvir (DAC) with or without ribavirin in the treatment of Egyptian chronic HCV patients compared with the use of brand drugs. MATERIALS AND METHODS: An observational study that included 234 Egyptian chronic HCV patients was carried out. Patients were classified into two groups: group A (101 patients) received brand SOF 400 mg plus brand DAC 60 mg and group B (134 patients) received generic SOF 400 mg plus generic DAC 60 mg with or without ribavirin for 12 weeks. The end point was a sustained virological response at 12 weeks after treatment. RESULTS: Thirty-eight (37.2%) patients in group A were treatment experienced compared with 12 (9.02%) patients in group B; there were 39 (38%) cirrhotic patients in group A and 22 (16.5%) cirrhotic patients in group B. In group A, 50% of patients received ribavirin, while in group B, 42.1% of patients received ribavirin. All patients were followed up; all of them attended their week 12 post-treatment visit with negative HCV RNA, with achievement of sustained virological response at 12 in 100% of patients receiving generic drugs (group B) and 99% of patients receiving brand drugs (group A). Generic SOF and DAC were well tolerated, with mild adverse events including fatigue and headache. CONCLUSION: Use of generic SOF and DAC with or without ribavirin is an extremely effective and a well-tolerated treatment for Egyptian chronic HCV patients.

Fluoroscopic subtraction Eustachian tubography: initial feasibility test in a cadaver model.

OBJECTIVES: To evaluate the technical feasibility of direct Eustachian tube catheterisation and subtraction Eustachian tubography in a cadaver model. METHODS: A total of 12 separate sessions were performed on both sides of the Eustachian tube (ET) in six human cadavers. Cadavers were positioned for the submentovertical view on a fluoroscopy table. Endoscopy-guided ET selection was used in the first three cadavers, whereas fluoroscopy-guided ET selection was used in the remaining three. Eustachian tubography was performed by injecting 2 ml of contrast media through a 5-Fr catheter. We recorded the success of ET selection, number of attempts, procedure time, and tubography quality using native and subtraction images (range, 0-3). RESULTS: Both endoscopy- and fluoroscopy-guided selections were successfully performed in five of six sessions (83.3%). There were no statistically significant differences between the endoscopy- and fluoroscopy-guided procedures in terms of the number of attempts, procedure time, rate of immediate contrast leak to the middle ear cavity, and quality of tubography (p > 0.05). An excellent quality of tubography was obtained in 83.3% (10 of 12 sessions) of subtraction images and in 33.3% (4 of 12 sessions) of native images. The tubography quality score was significantly higher for the subtraction images than for the native images (p = 0.04). CONCLUSION: Subtraction Eustachian tubography using direct catheterisation seems to be technically feasible. The entire ET can be well visualised; thus, this technique can be used as a simple tool for assessment of ET function and anatomy. KEY POINTS: • Direct catheterisation of the Eustachian tube is technically feasible. • The entire Eustachian tube could be well visualised by direct Eustachian tubography. • Subtraction Eustachian tubography images have better image quality than native images. • Subtraction Eustachian tubography can provide objective assessment of ET function and anatomy.

Fluoroscopic Gastroduodenal Stent Placement in 55 Patients with Endoscopic Stent Placement Failure.

PURPOSE: To evaluate the technical feasibility and clinical effectiveness of fluoroscopic self-expandable metal stent (SEMS) placement in malignant gastroduodenal obstructions after failed endoscopic SEMS placement. MATERIALS AND METHODS: Between September 2010 and July 2017, 874 patients underwent endoscopic SEMS placement for dysphagia caused by malignant gastroduodenal obstructions. Endoscopic SEMS placement failed in 55 of 874 patients (6.3%). These patients were referred for fluoroscopic SEMS placement. In case of failed fluoroscopic SEMS placement, combined endoscopic and fluoroscopic SEMS placement was attempted at the same setting. RESULTS: Fluoroscopic SEMS placement was technically successful in 40 of 55 patients (72.7%). Combined endoscopic and fluoroscopic SEMS placement was technically successful in 6 of 15 patients with fluoroscopic SEMS placement failure. Failures in the nine patients were due to complete obstruction (n = 5) and acute angulation at the stricture site (n = 4). The overall technical success rate was 83.6% (46/55). Clinical success was achieved in 95.6% of patients (44/46). Complications occurred in 7 of 46 patients (15.2%), including tumor overgrowth (n = 3), SEMS migration (n = 3), and bleeding (n = 1). The median SEMS patency and patient survival periods were 515 (95% confidence interval (CI), 266.6-761.5) and 83 (95% CI 60.6-105.4) days, respectively. CONCLUSIONS: Fluoroscopic SEMS placement is technically feasible and clinically effective in cases of endoscopic SEMS placement failure. A combined endoscopic and fluoroscopic approach increases the technical success rate after failure of the endoscopic or fluoroscopic approach. LEVEL OF EVIDENCE: Level IV.